ACT Observation Questionnaire

Advanced Chiropractic Techniques Observation Questionnaire
Name*

First NameLast Name
Gender*

MaleFemaleNon-BinaryDo not wish to identify
We were very pleased to have you attend our technique hands-on simulation lab in Atlanta, Georgia this past weekend.

As part of this weekend, you accumulated data on your performance in a variety of scenarios. We would appreciate it if you could fill in your collected data with the two questions below.

When your observers observed your arm swing, what did they report?

	Decreased L Arm Swing	Decreased R Arm Swing	Decreased on both sides	Equal Arm Swing
Observer 1
Observer 2
Observer 3
Observer 4

When your team observed your head and eye pursuit, what eye movement was observed?

	Rightward Eye Movement	Leftward Eye Movement	Both Eyes Moved in direction of pursuit	No Noticeable Movement
Observer 1
Observer 2
Observer 3
Observer 4

Should be Empty: