Up to $800 NYC Auditory Technology Study Survey

1.Contact Info(Required.)

Full Name:

Email:

Phone:

Gender:

Age:

City, State:

2.What is your date of birth?(Required.)

DOB

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

3.To see if you are eligible for the study, I need to ask you a few personal health questions. You don’t have to answer any question you don’t feel comfortable answering. 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

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

Yes

5.What is your:(Required.)

Job Title:

Industry:

6.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)

7.Do any of the following apply regarding your hearing? Note: if you have hearing loss but it has not been diagnosed by a doctor, please select "None of the above".(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

8.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

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

Yes

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

Yes

12.If you wear a hearing aide (OTHERS SKIP) is it...

an over the counter hearing aid that you purchased on your own

hearing aid precsribed by an audiologist

Other (please specify)

13.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

14.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

Up to $800 NYC Auditory Technology Study

About the study