Pre-Survey

Pre-Survey

This survey has two parts. The first section will have statements that you you will rate from strongly disagree to strongly agree. Please answer them honestly. The second section will have a series of questions to assess your current cognitive skills. Just do your best, it is okay if you do not get them all right. The final page will allow you the opportunity to provide feedback.
Full Name*

First NameLast Name
Do you have any health conditions that may affect your cognitive abilities (such as memory, attention, or problem-solving)? Examples include ADHD, dementia, brain injury, or learning disabilities. Please describe any that apply.*

You are now beginning Section 2.

Please take your time and do your best. Read each instruction carefully before you start each task. You will not be able to go back. You got this!

Please read the story on the next page and then answer the questions about it on the next page.

At 9:45 a.m., Evan entered the library. He had his backpack, phone, and wallet with him. He returned one book at the desk and paid a $5 late fee with cash. He wanted to check out two more books, but realized he forgot his library card.

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Please answer the following questions about the story. If you do not know, please put "no answer" in the box.
What time did Evan enter the library?*
What 3 items did he bring with him?*
How much was his late fee?*
How did he pay for his late fee (card, cash, coins, etc.) *
What did Evan forget to bring?*

Follow the instructions provided below and use the picture on the next page to provide your answer.
Count how many times you see

the letter R.

R S T R B T F B S T P P B R T S

P A S T R R T S F B S T P B F A

T S B A B R S T F S T S P B F A
Answer here:*

Follow these instructions and use the picture on the next page to answer:
Count how many times you see the letter T come immediately after the letter S.

R S T R B T F B S T P P B R T S

P A S T R R T S F B S T P B F A

T S B A B R S T F S T S P B F A
Answer here: *

R S T R B T F B S T P P B R T S

P A S T R R T S F B S T P B F A

T S B A B R S T F S T S P B F A
Answer here:*

Thank you!

Thank you for completing this pre-survey. If you faced any issues, or have any comments/concerns regarding this survey, please provide them in the box below. When you are done, hit submit to save your answers.
Should be Empty:

Section 1