$175+ Menlo Park Tech Study Survey

1.Contact Info(Required.)

Full Name:

Email:

Phone:

Gender:

Age:

Date of birth (MM/DD/YYYY)

City, State:

2.Have you participated in any hearing related research study in the last 3 months? (Required.)

Yes

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

Yes

4.Are you willing to travel to Menlo Park for the in-person screening session?(Required.)

Yes

5.Are you willing to travel to Burlingame for future paid voluntary research studies? (Required.)

Yes

6.What is your:(Required.)

Job Title:

Industry:

7.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)

8.Do any of the following apply regarding your hearing?(Required.)

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

9.Do you have any neurological deficits such as Dementia, Alzheimer’s disease, Parkinson’s disease, Multiple Sclerosis, aphasia or dysarthria, depression, or anxiety?(Required.)

Yes

$175+ Menlo Park Tech Study

About the study