Feedback Form: Kit for Kids

Name*
First Last
Email*
Phone*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Organization/School Name*
What is your position? (title and grades if applicable)*
What is your connection to autism?*
Which grade(s) used the materials?*
How many students participated in the lesson?*
In what way(s) did you use the materials to teach students about autism?*
Who led the story-telling?*
- Teacher
- Parent
- Student
- Other
Please indicate your level of satisfaction with the overall content and quality of the following.*
N/A Poor Fair Good Excellent
Overall Program
Information about autism
Please indicate your level of satisfaction with the overall content and quality of the following.*
N/A Poor Fair Good Excellent
Lesson Plan
Nick Booklet
Poster
Video
Activity Workbooks
Based on what you’ve seen and heard, do you think your students' attitudes towards peers with autism have changed as a result of the lesson? Please explain.*
How did you hear about Kit for Kids?*
What questions were not covered by the presentation? If so, what were they?*
What additional autism related support (if any) do you or your school need?*
Do you have any suggestions for how we can improve this program?*
Do you have any suggestions for future directions or other programming opportunities?*

	N/A	Poor	Fair	Good	Excellent
Overall Program
Information about autism