PNW Adapted Toy Library Enrollment Survey

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This is the enrollment form for the Pacific Northwest Adapted Toy Library. Please answer the following questions to help us better understand how the library can be most beneficial to you.
If you need assistance or accommodations to complete this survey please contact uwtcat@uw.edu

Name

Email Address *

Phone Number

Has the learner (receiver of disability services) used an adapted toy before? *

Yes

What is the learner's favorite toy? (adapted or non-adapted)

If yes, what is their most commonly used adapted toy?

If the learner has used an adapted toy before, what type of adapted switch do they most often use?

What is the biological age of the intended user of the adapted toys? *

<1 year old

2-4 years old

5-6 years old

7-9 years old

10-12 years old

13-15 years old

16-18 years old

18+ years old

Does the learner act younger than their biological age? *

Yes

Sometimes

Other:

What is the learner's current educational level? *

Preschool

Elementary School

Middle School

High School

Transition Program

College

Work

Other:

Does the learner have trouble letting you know what they want? *

Yes

Sometimes

Other:

Does the learner ignore some sounds? *

Yes

Sometimes

Other:

Does the learner sometimes ignore things or people that are moving? *

Yes

Sometimes

Other:

Does the learner ignore some lights? *

Yes

Sometimes

Other:

Does the learner have trouble hearing? *

Yes

Sometimes

Other:

Does the learner have difficulty concentrating? *

Yes

Sometimes

Other:

Does the learner find it hard to read or write? *

Yes

Sometimes

Other:

Does the learner have trouble moving around a room? *

Yes

Sometimes

Other:

Does the learner have trouble pushing buttons? *

Yes

Sometimes

Other:

Does the learner have trouble operating switches? *

Yes

Sometimes

Other:

Does the learner have trouble using touch to activate a click on a touchscreen? *

Yes

Sometimes

Other:

Is the learner sensitive to flashing lights? *

Yes

Sometimes

Other:

Is the learner sensitive to loud noise? *

Yes

Sometimes

Other:

Is the learner sensitive to touch or certain textures? *

Yes

Sometimes

Other:

Please let us know which features we haven't discussed you LIKE in a toy for this learner?

Please let us know which features a toy may NOT HAVE?

If you choose, help us better understand the learner by specifying a diagnosis, if any (optional)

How did you find out about the PNW Adapted Toy Library?

What do you hope to gain from the PNW Toy Library? What developmental goals do you hope that the toys will help the learner with?

What do you think would be the ideal loan time for a toy from the library?

1 week

2 weeks

3 weeks

1 month

Other:

Clear selection

What city do you live in?

Additional Comments

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