Cognitive Feedback Form
Please provide your feedback on your recent cognitive experience or session. Your input helps us improve future activities.
Participant Name
*
First Name
Last Name
Email Address
*
example@example.com
Session or Activity Title
*
Date of Session or Activity
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate the following aspects of your cognitive experience:
*
Rows
Poor
Fair
Good
Very Good
Excellent
Clarity of Instructions
1
2
3
4
5
Level of Engagement
6
7
8
9
10
Challenge Level
11
12
13
14
15
Relevance to Goals
16
17
18
19
20
Quality of Materials
21
22
23
24
25
How would you rate your overall cognitive experience?
*
1
2
3
4
5
Which cognitive skills or areas were most impacted during this session? (Select all that apply)
*
Attention
Memory
Problem Solving
Reasoning
Creativity
Other
Did you encounter any difficulties during the session?
*
No difficulties
Minor difficulties
Moderate difficulties
Significant difficulties
Other (please specify)
Please describe any specific challenges or barriers you faced.
What suggestions do you have for improving future cognitive sessions or activities?
Do you have any additional comments or feedback?
Submit Feedback
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