Family Center on Deafness Survey

Before you begin, here are some notes:

A. Please fill out this survey only once for each person who is deaf or hard of hearing.

B. Please do not complete this survey if the individual is not living in the state of Florida.

C. Please answer as many questions as possible in the survey for us to better serve you.

Question Title

* 1. Which age group does the individual with hearing loss fall under?

0 - 3 years old (infants)

4 - 5 years old (preschool)

5 - 11 years old (elementary school)

12 - 14 years old (middle grade)

15 - 17 years old (secondary, high school)

18 - 64 years old (adults)

65 - 99 years old (seniors)

Prefer not to say

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* 2. Which County in Florida is the individual with hearing loss currently living in?

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* 3. Please enter the zip code the individual with hearing loss is currently living in:

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* 4. Which Gender does the individual with hearing loss most identify by?

Male

Female

Other

Prefer not to say

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* 5. What is the ethnicity of the individual with hearing loss?

White / Caucasian

Black / African American

Hispanic or Latino

Asian

Other

Prefer not to say

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* 6. Does the individual have a hearing loss in one ear or both ears?

One ear

Both ears

Not sure

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* 7. Is one or both of the individual's parents, or Guardian(s) deaf/hard of hearing?

One of them is deaf/hard of hearing

Both of them are deaf/hard of hearing

Both of them are not deaf/hard of hearing

Have a guardian who is deaf/hard of hearing

The individual lives by themselves

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* 8. Does the individual with hearing loss have one or more deaf or hard of hearing household member?

Note: If Yes - please be sure to fill out this survey for each member

Yes

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* 9. Does the individual with hearing loss attend residential schools / Schools for the Deaf?

Yes

Family Center on Deafness Survey

Question Title

* 1. Which age group does the individual with hearing loss fall under?

Question Title

* 2. Which County in Florida is the individual with hearing loss currently living in?

Question Title

* 3. Please enter the zip code the individual with hearing loss is currently living in:

Question Title

* 4. Which Gender does the individual with hearing loss most identify by?

Question Title

* 5. What is the ethnicity of the individual with hearing loss?

Question Title

* 6. Does the individual have a hearing loss in one ear or both ears?

Question Title

* 7. Is one or both of the individual's parents, or Guardian(s) deaf/hard of hearing?

Question Title

* 8. Does the individual with hearing loss have one or more deaf or hard of hearing household member?Note: If Yes - please be sure to fill out this survey for each member

Question Title

* 9. Does the individual with hearing loss attend residential schools / Schools for the Deaf?

* 8. Does the individual with hearing loss have one or more deaf or hard of hearing household member?

Note: If Yes - please be sure to fill out this survey for each member