American Printing House for the Blind
FIELD TEST EVALUATOR FORM
The American Printing House for the Blind (APH) regularly conducts field tests of new products that are under development. APH uses the comments and recommendations gathered from experts in the field to refine and improve products before actual production. If you would like to be considered for future field test opportunities, please complete the form below and return to:
Laura Zierer
Research Department
American Printing House for the Blind
1839 Frankfort Avenue
P.O. Box 6085
Louisville, KY 40206-0085
Phone: (502) 899-2279
Fax: (502) 899-2269
E-mail:
NOTE: The questions on thisform are in reference to theindividual (e.g., TVI)completingtheform.
Date:
Name:
Professional Certifications and Degrees:
Job Title/Description:
School/Agency:
Work Address:
City, State, Zip Code:
Work Phone:Ext:
Work Fax:
E-mail:
Home Address (optional):
City, State, Zip Code (optional):
Home Phone (optional):
Cell Phone (optional):
Field Tester Classification:
Parent of a Child with Visual Impairment
Adult Consumer of APH Products
Professional in the Field
Do you work with students or clients/consumersin any of thefollowing categories?
Infant/Preschool
Elementary
Middle school
High school
Adults
In a typical year, what is your caseload?
Small (1-3 students/clients/consumers)
Medium (4-10 students/clients/consumers)
Large (10+ students/clients/consumers)
Your Visual Function:
No Visual Impairment
Low Vision
Legally Blind
No Functional Vision
Your Preferred Reading Medium:
Large Print
Regular Print
Braille
Years of Experience Reading Braille as your Preferred Reading Medium:
Ethnicity/Race [US Department of Education categories]:
Hispanic of any race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
AgeRange:
18-30
31-45
46-65
65 and older
Areas of Interest/Expertise (Check all that apply):
Adult Life
Assessment
Braille
CVI
Daily Living
Early Childhood
Employment
Low Vision
Math
Multiple Disabilities
Music
O & M
Physical Fitness
Recreation
Rehab Teaching
Science
Social Studies
Spanish
Tactile Graphics
Technology
Transition
Are you available for summer field-testing activities, between June and August?
Yes No
Initial APH Contact:
Where Contacted:
Have you been an APH Field Tester in the past?
Yes No
Is there a particular product that you would like to test or feel especially qualified to test? Why?
THANK YOU FOR YOUR INTEREST IN FIELD TESTING FOR THE AMERICAN PRINTING HOUSE FOR THE BLIND.