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Audiology Client Survey
Please fill out for the
person receiving services
(i.e. self, child, parent)
OK
*
1.
I received...
(Required.)
Hearing Testing
Hearing Aid Services
Cochlear Implant Services
*
2.
Appointment started promptly
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
*
3.
Center facilities were acceptable
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
*
4.
Professionalism of the receptionist was appropriate
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
*
5.
Professionalism of the clinician was appropriate
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
*
6.
Fees for service were affordable
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
*
7.
I experienced quality service while being tested
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
*
8.
Results were explained in a way I could understand
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
*
9.
I would recommend the Center to others
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Please answer the following questions if you were fit with a hearing aid or cochlear implant:
*
10.
My device was ready when promised
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Overall Experience:
*
11.
Why did you choose the Center?
(Required.)
*
12.
The best part about the services I received was...
(Required.)
*
13.
How can we change our services to benefit you more?
(Required.)
*
14.
Age Range
(Required.)
0-18
19-39
40-60
60-80
80+
*
15.
Gender:
(Required.)
Male
Female
Non-Binary
Prefer Not to Disclose
Thank you for your feedback! We do not release your personal data to anyone.
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