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CAT Feedback Form
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Response
First Name
Required
*
MI
Last Name
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*
Email
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*
Phone Number
Date of Communication Event/Services Rendered
Button, Start Date - Pick Using Date Picker Widget
Button, Start Date - Clear/Reset Selected Date
Format as: two digits for month, dash, two digits for day, dash, four digits for year (yyyy-mm-dd)
Service Type
ASL Interpreting of Pre-recorded Media
ASL/English Interpreter (In Person)
ASL/English Interpreter (Virtual)
ASL/English Interpreter (In Person) & Realtime Captioning
ASL/English Interpreter (Virtual) & Realtime Captioning
Captions of Pre-recorded Media
Live Realtime Captioning (CART)
Transcript Only (Meaning-for-Meaning)
Service Event
Campus Event
Classroom Instruction
Conference
Meeting
Workshop/Training
Other
I would like to report a
Concern
Compliment
Other
Other
Service Provider Name
My compliment is regarding the following area(s): (Please check all that apply.)
[select]
Professionalism
Dress
Effectiveness of service provided
Ethical business practices
Transcript
Other
clear
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Other Compliment
My concern is regarding the following area(s): (Please check all that apply.)
Professionalism
Effectiveness of service provided
Ethical violation
Transcript
Other Concern
Please briefly describe the areas noted above providing specific examples:
I would like to be contacted to discuss this matter further
I would like to be contacted to discuss this matter further
Yes
I would like to be contacted to discuss this matter further
No
If you would like to be contacted by the Accessibility Coordinator prior to this internal communication, please let us know
NO, I do not wish to be contacted. Please address my concern.
YES, I would like to be contacted to discuss this ...further prior to internal communication or action.
Preferred Method of Contact: