Zephyr-TEC Evaluation

Zephyr-TEC Evaluation

Date of Eval:

How did you hear about us?

SectionI. CLIENT INFORMATION

Company:

Client:Phone:

Job Title:

Address:

City:State:Zip:

Contact:Phone:

E-mail:

Please list below any relevant additional contact people:

Disability Manager/Rehab Counselor:

I/S Person:

Human Resources:

Doctor:

Attorney:

Other:

Are you currently working?  Yes  No
If YES, must complete Section III
If NO, how long have you been off work?
What kind of work are you considering?
Will you be purchasing a computer?  Yes No
Complete Section II in either case
Are you currently injured?  Yes  No
If YES must complete section IV
If NO, are you considering speech software to:

 Prevent Injury Increase My Productivity Other

Section II. HARDWARE

PLEASE NOTE: Dragon NaturallySpeaking Professional for the PC requires:

Intel Core2Duo 2.5 GHz or higher (i3, i5, i7 Series chips yieldsuperior performance)

4 GB RAM minimum

5 GB Free disk space

Windows compatible sound card

DVD drive for installation

Window 7 or Windows 8, 8.1(32 and 64-bit)

Internet Explorer 9.0 or higher (for Help files)

Microsoft Office 2007, 2010, 2013 (if used)

Please check the appropriate box:

Desktop PC Laptop PCTablet PC Mac

Brand /Model:______

1.Hard Disk Space Available (total and free):

Free Space: GBTotal: ______GB

2.Operating System:

Windows:Edition (Home, Pro, etc.):

Version (7, 8, 8.1)

MAC: OS X (Mavericks, Yosemite, etc.): _____

 Version ______

Other (please specify)______

3.RAM (Total physical RAM in MB):

 2.0 GB 3.0 GB  4.0 GB 8 GB Other:______

4.Processor Type/Speed

Intel DualCore: i3 i5 i7Processor Speed: GHz

Intel QuadCore: i3 i5 i7Processor Speed: GHz

AMD: K-6 Athlon OtherProcessor Speed: GHz

 Other (please specify) ______Processor Speed: GHz

5.Sound System

Windows Compatible Built-in Onboard

SoundMAX Other (please specify) ______

6.CD/DVD-ROM Specifications(note Dragon requires a DVD-ROM for installation):

 DVD-ROM DVD/RW USB Drive External Drive Other

7.Network Type:

Windows ServerVersion (2008, 2012):

Terminal Services used?  Yes No

RDP Used?  Yes No

 Citrix Version:

 Other (please specify) ______

8.Terminal Emulation Programs:

Please specify:______

Section III. WORK ENVIRONMENT
(Complete if prospective client is currently working)

1.What type of office environment are you working in?

 Cubicle: No dividers Dividers at shoulder height Dividers-tall

 Closed door office Other: ______

2.What are the sources of noise at your workstation?:

 Interruptions Background noise Phones

 Voices of co-workers Noise from printers or photocopiers

 Street/external building noise Other:

3.Please circle the level of noise overall(1 = low and 5 = high)

12345

4. Provide a brief description of the following task requirements and the percentage of the day they are performed:

Task / Description of task / % of day
Typing
Telephoning
10 key
Mousing
Handwriting
Other:

Section IV. INJURY/DISABILITY AND LIMITATIONS
(Complete for injured clients only)

1. Describe injuries/disability:

2. Describe limitations set by physician: ______

a.) Keyboard usage limited to:

b.) Mouse usage:

c.) Manual dexterity/fine manipulation: ______

3.) Will you be returning to:  Job of injury  New position

4 .) Will there be modifications to the job? If so, what are they? ______

6.) Do you use a telephone headset to answer your phone? Yes  No

Section V. SOFTWARE (Must be completed by everyone)

1. Please indicate the software products used by the prospective user:

Rate your knowledge of the programs:

BeginnerIntermediateAdvanced:

Program / Version (i.e.2007, 2010, 2013, 365) / % of usage
per day / # of months or years of use / Beginning
Intermediate
Advance
MS Word
MS Excel
MS Outlook
MS PowerPoint
OTHER PROGRAMS: / List all other programs used/accessed (proprietary, custom, etc.)

2. How many different computer programs will you be using concurrently?

3. Would you benefit from the use of an additional medical or legal vocabulary?

Thank you for completing this form. We will review the information and either contact you with further questions or provide a more detailed training proposal.

Zephyr-TEC Corp.

877-493-7497