Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Attendance Starting Date *

MM

DD

YYYY

Attendance Ending Date *

MM

DD

YYYY

Having completed your training, how useful are your travel skills to you? *

Extremely useful

Useful

Somewhat useful

Not useful

How useful are your Braille skills? *

Extremely useful

Useful

Somewhat useful

Not useful

How useful are your typing/computer literacy skills? *

Extremely useful

Useful

Somewhat useful

Not useful

How useful are your home economics/daily living skills? *

Extremely useful

Useful

Somewhat useful

Not useful

How useful are your industrial arts skills (if applicable)?

Extremely useful

Useful

Somewhat useful

Not useful

How useful was your Remedial Education/GED training (if applicable)?

Extremely useful

Useful

Somewhat useful

Not useful

Please rate your overall training at the Center:

Excellent

Satisfactory

Needs Improvement

Unsatisfactory

Would you recommend potential students to the Center? *

Yes

No

Have you adjusted to family life since leaving the center? *

Yes

No

Have you noticed a change in your family’s attitude about blindness since completing your training?

Yes

No

Do you participate more in social activities since completing training at the Center? *

Yes

No

Do you feel more comfortable in social settings since completing training at the Center? *

yes

no

Rate your present comfort level while participating in social activities: *

Very Comfortable

Comfortable

Somewhat comfortable

Uncomfortable

Are you currently employed? *

yes

no

If yes, do you work part-tme or full-time? (Full-time is defined as 30 hours or more a week.)

Full-time

Part-time

If you are working, is the training that you received at the Louisiana Center for the Blind beneficial to you in your employment?

yes

no

Did you get your job as a result of Louisiana Center for the Blind services?

yes

no

Are you currently in school? *

yes

no

Did you pursue higher education following your training at the Center?

yes

no

If you are in school or if you pursued higher education after training at LCB, please check all that apply.

Community College

University

Technical School

Graduate School

Other

How would you rate the physical facility (building) while you were in training? *

Excellent

Satisfactory

Needs Improvement

Unsatisfactory

How would you rate the living accommodations during your training? *

Excellent

Satisfactory

Needs Improvement

Unsatisfactory

Do you use Braille? *

Always

Sometimes

Never

Do you use the computer? *

Always

Sometimes

Never

Do you cook? *

Always

Sometimes

Never

Do you travel independently using the cane? *

Always

Sometimes

Never

If applicable, do you attempt any industrial arts activity or home maintenance projects?

Always

Sometimes

Never

How would you rate your instruction in your Braille class? *

Excellent

Satisfactory

Needs Improvement

Unsatisfactory

How would you rate your instruction in computer class? *

Excellent

Satisfactory

Needs Improvement

Unsatisfactory

How would you rate your instruction in your home economics/daily living skills class? *

Excellent

Satisfactory

Needs Improvement

Unsatisfactory

How would you rate your instruction in your cane travel class? *

Excellent

Satisfactory

Needs Improvement

Unsatisfactory

If applicable, how would you rate your instruction in the industrial arts class? *

Excellent

Satisfactory

Needs Improvement

Unsatisfactory

Did you participate in routine “staffings” while a student at the Center? *

Yes

No

How would you rate your overall experience with the Center staff? *

Excellent

Satisfactory

Needs Improvement

Unsatisfactory