Audiology Research Intake Form

Audiology Research Intake Form

Please answer the following questions and a Research Assistant will reach out to you shortly.

Thank you for your interest in research at Boston Children's Hospital!

Participant Last Name*

Participant First Name*

Participant Date of Birth*

Participant Sex Assigned at Birth

Male

Female

Other

If other, please elaborate

Participant's Native Language*

Name of Person Completing Form (Last Name, First)

Relationship to Participant

Select or enter value

If other, please clarify

Email Address

Phone Number (XXX-XXX-XXXX)

Phone

Preferred Contact Method*

Email

Phone

Let us know when you'd like us to reach out:

Does participant have hearing loss?

Yes

No

Is Hearing Loss in One or Both Ears?

One - Left Ear

One - Right Ear

Both - Left and Right Ears

Degree of Hearing Loss*

Select

Does the participant use any personal hearing technology?*

Yes

No

If yes, which device(s)?

Please select all that apply.

Traditional Hearing Aid

Bone-Anchored Hearing Device

CROS Hearing Aid System

Cochlear Implant

Other

If other, please explain:

Has the participant ever had an operation to put tubes in their ears?*

Yes

No

Any additional chronic physical or mental health disorders?*

Yes

No

If yes, please explain:

How did you hear about this study?*

Select or enter value

Please explain:

Thank you for completing our survey!

A member of our team will reach out to you shortly.

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