Menlo Park / Burlingame Technology Study Survey

1.Contact Info(Required.)

Full Name:

Email:

Phone:

Gender:

Age:

Date of birth (MM/DD/YYYY)

City, State:

2.To see if you are eligible for the study, you will be asked a few personal health questions. Your answers will be recorded, but your information will only be used for the purposes of this study. Should you qualify, are you interested in participating in this research?(Required.)

Yes

3.Have you ever done a hearing study with Exponent in the past?(Required.)

Yes

4.Are you able to read and understand English?(Required.)

Yes

5.Are you willing to travel to Burlingame for the research study if needed?(Required.)

Yes

6.Are you willing to travel to Menlo Park for the research study if needed?(Required.)

Yes

7.What is your:(Required.)

Job Title:

Industry:

8.Which of the following best describes your ethnicity?(Required.)

East Asian (includes Chinese, Japanese, Korean)

South Asian (includes Asian Indian, Pakistani, Bangladeshi)

Southeast Asian (includes Cambodian, Filipino, Thai, Vietnamese)

Black, African American, or African (includes African American, Barbadian, Caribbean, Ethiopian, Ghanian, Haitian, Jamaican, Liberian, Nigerian, Somali, South African)

Hispanic, Latino, or Spanish (includes Colombian, Cuban, Dominican, Ecuadorian, Honduran, Mexican or Mexican American, Puerto Rican, Salvadoran, Spanish)

Middle Eastern or North African (includes Afghan, Algerian, Egyptian, Iranian, Iraqi, Israeli, Lebanese, Moroccan, Syrian, Tunisian)

Native Hawaiian or other Pacific Islander (includes Chamorro, Chuukese, Fijian, Marshallese, Native Hawaiian, Palauan, Samoan, Tahitian, Tongan)

American Indian or Alaska Native (includes Central or South American Indian)

White (includes Dutch, English, European not listed, French, German, Irish, Italian, Norwegian, Polish, Scottish)

9.Do any of the following apply regarding your hearing?(Required.)

Diagnosed conductive hearing loss, mixed hearing loss, or central auditory processing disorder

An existing hearing assistive device (i.e. cochlear implant, bone-anchored hearing aid, or middle ear implant)

History of ear pain or discomfort, chronic ear infections, or ear drainage that could interfere with my ability to wear and use a hearing aid

A typical ear physiology or prior surgery that could impact my ability to wear and use a hearing device

None of these apply to my hearing

10.Do you have any neurological conditions such as Dementia, Alzheimer’s disease, Parkinson’s disease, Multiple Sclerosis, aphasia or dysarthria, depression or anxiety that could affect your participation?(Required.)

Yes

11.Do you have normal 20/20 vision or vision corrected to normal 20/20 vision with with glasses or contacts?(Required.)

Yes

13.Do you wear a hearing aid?(Required.)

Yes

14.If you wear a hearing aid, which of the following most accurately describes your hearing status without hearing aids? (SKIP IF YOU DO NOT WEAR HEARING AIDS)

I feel no difficulty

I feel some difficulty

I feel significant difficulty

I cannot hear without hearing aids

15.Which, if any, of the following apply to you? (select all that apply)(Required.)

You have trouble hearing speech in noisy places

You find it hard to follow speech in groups

You have trouble hearing on the phone

Listening makes you tired

You need to turn up the volume on the TV or radio, and other people complain it's too loud

None of these apply to me

Menlo Park / Burlingame Technology Study

About the study