Experience of Care Parent Survey

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* 1. When your child had their hearing screened shortly after birth, how were your baby’s results delivered to you?

Never received results in hospital

I was told the results

I got a copy of the results

I was told and got a copy of the results

I don’t remember

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* 2. Did your primary care provider have the results of your baby’s newborn screening in their records at your first well-baby visit?

Yes

Don't Know

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* 3. From the time your baby had the screening test until the time his/her hearing loss was confirmed, how often were you able to get the help you needed for questions related to your child’s hearing loss from the health professionals listed below.

	Never	Sometimes	Usually	Always	N/A
Nursery nurse	Nursery nurse Never	Nursery nurse Sometimes	Nursery nurse Usually	Nursery nurse Always	Nursery nurse N/A
Primary Care Provider or Pediatrician	Primary Care Provider or Pediatrician Never	Primary Care Provider or Pediatrician Sometimes	Primary Care Provider or Pediatrician Usually	Primary Care Provider or Pediatrician Always	Primary Care Provider or Pediatrician N/A
Audiologist	Audiologist Never	Audiologist Sometimes	Audiologist Usually	Audiologist Always	Audiologist N/A
Ear, Nose, Throat Doctor	Ear, Nose, Throat Doctor Never	Ear, Nose, Throat Doctor Sometimes	Ear, Nose, Throat Doctor Usually	Ear, Nose, Throat Doctor Always	Ear, Nose, Throat Doctor N/A
Early Intervention Services Coordinator	Early Intervention Services Coordinator Never	Early Intervention Services Coordinator Sometimes	Early Intervention Services Coordinator Usually	Early Intervention Services Coordinator Always	Early Intervention Services Coordinator N/A
Teacher of the Deaf/Hard of Hearing	Teacher of the Deaf/Hard of Hearing Never	Teacher of the Deaf/Hard of Hearing Sometimes	Teacher of the Deaf/Hard of Hearing Usually	Teacher of the Deaf/Hard of Hearing Always	Teacher of the Deaf/Hard of Hearing N/A

Other (please specify)

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* 4. From the time you were told your child had a permanent hearing loss until you started early intervention services, how often were you able to get specific information on each of the following subjects?

	Never	Sometimes	Usually	Always	N/A
Communication Choices	Communication Choices Never	Communication Choices Sometimes	Communication Choices Usually	Communication Choices Always	Communication Choices N/A
How things are paid for	How things are paid for Never	How things are paid for Sometimes	How things are paid for Usually	How things are paid for Always	How things are paid for N/A
Meeting other parents	Meeting other parents Never	Meeting other parents Sometimes	Meeting other parents Usually	Meeting other parents Always	Meeting other parents N/A
Hearing Aids and/or Cochlear Implants	Hearing Aids and/or Cochlear Implants Never	Hearing Aids and/or Cochlear Implants Sometimes	Hearing Aids and/or Cochlear Implants Usually	Hearing Aids and/or Cochlear Implants Always	Hearing Aids and/or Cochlear Implants N/A
Use of Sign Language	Use of Sign Language Never	Use of Sign Language Sometimes	Use of Sign Language Usually	Use of Sign Language Always	Use of Sign Language N/A
Knowing where to go next in the process	Knowing where to go next in the process Never	Knowing where to go next in the process Sometimes	Knowing where to go next in the process Usually	Knowing where to go next in the process Always	Knowing where to go next in the process N/A
Early Intervention programs	Early Intervention programs Never	Early Intervention programs Sometimes	Early Intervention programs Usually	Early Intervention programs Always	Early Intervention programs N/A
Causes of Hearing loss	Causes of Hearing loss Never	Causes of Hearing loss Sometimes	Causes of Hearing loss Usually	Causes of Hearing loss Always	Causes of Hearing loss N/A

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* 5. If you would like to give us additional information on the above questions, or if there is anything else that you would like to tell us, please add your comments below. Thanks again for your time!

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* 6. Who did you receive your Parent Resource Guide from?

Audiologist

Early Intervention Provider

Guide By Your Side Parent Guide

Ear Nose & Throat Physician

Primary Care Doctor

Other (please specify)

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* 7. If you would like follow up from the NE-EHDI Program, please provide your contact information below.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number