Hearing Aid Action Survey

1. Please fill out the info below. You can leave it blank if you prefer to remain anonymous.

Please fill out the info below. You can leave it blank if you prefer to remain anonymous. Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

2. Do you or your child/children wear hearing aids everyday?

Do you or your child/children wear hearing aids everyday? Yes, I am an adult who wears hearing aids.

Yes, I am a parent of a child who wears hearing aids.

No, I do not wear hearing aids every day.

3. How many years have you or your child/children had your current hearing aids?

How many years have you or your child/children had your current hearing aids? LESS THAN 1 YEAR

1 - 2 YEARS

2 - 3 YEARS

3 - 5 YEARS

MORE THAN 5 YEARS

I'M NOT SURE

4. How many hearing aids have you had and/or purchased since the initial diagnosis of your hearing loss?

How many hearing aids have you had and/or purchased since the initial diagnosis of your hearing loss? Number of Hearing Aids

5. How did you pay for your hearing aids?

How did you pay for your hearing aids? I paid for them with my own money.

My insurance company paid for them.

My insurance covered some and I paid the rest.

A state program paid for them.

They were donated.

Other

Other (please specify)

6. What was the approximate cost you paid for each hearing aid?

What was the approximate cost you paid for each hearing aid? Cost of Each Hearing Aid

7. If your insurance covered any portion of your hearing aids, please indicate how many dollars they covered (per hearing aid)?

If your insurance covered any portion of your hearing aids, please indicate how many dollars they covered (per hearing aid)? Dollars Covered By Insurance, per Hearing Aid

8. How is the cost of hearing aid repair covered?

How is the cost of hearing aid repair covered? My insurance company provides coverage for repairs.

A state program provides coverage for repairs.

I pay for repairs out of my pocket.

Other.

Other (please specify)

9. If you were a candidate for both the cochlear implant and hearing aids, would the amount of insurance coverage be a factor in your decision?

If you were a candidate for both the cochlear implant and hearing aids, would the amount of insurance coverage be a factor in your decision? Yes

No

10. On a Scale of 1 - 5, how interested are you in passing legislation requiring hearing aid coverage through your medical insurance?

On a Scale of 1 - 5, how interested are you in passing legislation requiring hearing aid coverage through your medical insurance? 1 - No interest at all

2 -

3 - Neutral

4 -

5 - Very interested, count me in for support

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