UNHSI Pediatric Audiology Survey

Survey of Pediatric Audiologists in Georgia

Please complete this survey if you are an Audiologist with experience in the audiological screening, evaluation and management of infants or children with hearing impairment birth to five years of age. Information will be used for a registry of pediatric audiologists available to provide services for infants identified through the Georgia Universal Newborn Hearing Screening and Intervention (UNHSI) program. Your responses will also provide baseline information for program improvement activities. The registry will be available on the Georgia UNHSI program website (http://health.state.ga.us/programs/unhs) and you will only be included with your permission.

Question Title

1. Do you currently provide audiological services for children birth to five years of age?

Yes

Question Title

2. Audiologist Demographics

Name: *

Company: *

Buisness Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *