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Survey

Please take a few moments to fill out the following survey.  Your input will help us improve our site.  Every  20th participant will be awarded a Starbucks gift certificate worth $10.  We thank you for your participation and good luck!

1.  Are you affiliated with (i.e., employed by or receiving services from):

   The Massachusetts Department of Mental Retardation

   Another mental retardation association

   Not affiliated with any mental retardation association

2.  Are  you a: 

        Parent     Service Provider     Therapist     Consumer

  Other:

3.  If Therapist: (Please check all appropriate.) 

  Occupational Therapist 

   Physical Therapist   Speech Therapist
  Recreational Therapist   Psychologist   Music Therapist
  Other:  

4.  If Service Provider: (Please check all appropriate.)

  Educator 

   Service Coordinator   Vocational Instructor
  Social Worker   Personal Care Provider  
  Other:  

5.  Diagnoses of Consumer(s): (Please check all appropriate.) 

  Mental Retardation 

   Autism/P.D.D.   Down Syndrome
  Speech/Language Disorder   Seizure Disorder   Visually Impaired
  Attention Deficit Disorder   Hearing Impaired   Acquired Brain Injury
  Cerebral Palsy  Other:

6.  Functional Limitations of Consumer(s): (Please check all appropriate.) 

  Vision 

   Memory/Organization   Mobility/Balance
  Hearing   Reaching/Lifting   Hand Use
  Speech   Other:

7.  Age of Consumer(s):

    0-10 Years   11-22 Years   23-55 Years     55+ Years

8.  Current Living Situation of Consumer(s): 

   Independent

   Community Residence (State operated)
   With Family   Community Residence
        (Privately operated)
   Nursing Home   State Institution
Other:

9.  Day/Work Education Program of Consumer(s):

  Habilitation/Leisure Program

   Supported Employment
  School/Special Education   Sheltered Workshop
  No Day/Work Program   Competitively Employed
Other:  

10.  How did you find out about this web site?  

  Adapted Activities Library Brochure

   Referred by Service Provider
  Another Web Site   Word of Mouth
  Web Search Other:

11.  What activities/products are you looking for?  (Please check all appropriate.) 

    Environmental Control 

     Communication   Computer Use
    Sensory Stimulation

    Cooking

   Recreation
    Self Care     Work Aids   Memory Aids
Other:

12.  Are you interested in purchasing any products described on this web site?  

  Yes   Maybe
   No If not, why not?  (Please check all appropriate.)
Didn't find what I needed
Not enough info to decide		 Didn't see anything new
 Other: 

13.  Did you find any information that you plan to use or to pass on to someone else?

Yes      No

14.  Please rate each of the areas of the site you visited:
 

     HOME PAGE
Clarity     Good   Adequate Poor
Amount of Text   Good   Adequate Poor

Comments: 
 

     FINDING THE RIGHT PRODUCT SECTION
Clarity     Good   Adequate Poor
Ease of Use   Good   Adequate Poor
Amount of Text   Good   Adequate Poor
Learned something new:     Yes       No

Comments: 
 

         MAKING THINGS MORE USABLE SECTION
Clarity     Good   Adequate Poor
Selected Topics   Good   Adequate Poor
Amount of Text   Good   Adequate Poor
Learned something new:     Yes       No

Comments: 
 

15.  What would make you visit the web site again?  (Check all that apply.)

  New Products   Links to Resources
  Articles   Bulletin Board to Share Information

Other:   

16.  Please rate the ease of moving around and using the site.

  Good   Adequate   Poor

Comments: 

Optional:  Tell us how to get in touch with you:

First Name:
Last Name:
E-mail:
Tel:
FAX:
City:
State
Country:

      

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