This questionnaire is designed for cochlear implant (CI) or hearing aid (HA) users who would like to participate in on-going research studies at the Center for Robust Speech Systems, Cochlear Implant Lab (CILab) at the University of Texas at Dallas. Prior to your particpation, some information regarding the history of your impairement and the device/processor/manufacturer specifications are needed to determine your eligibility. Please fill out the form to the best of your ability. If there are items you cannot answer, you may leave them blank and a member of the CILab will follow up with you after the survey is complete. Please note that not all of the questions are required, some of the questions are optional. In case of questions with the form, please contact any one of the following CILab members:
Research Coordinator: Taylor Lawson (taylor.lawson@utdallas.edu) Lab Manager: Dr. Juliana N. Angell (Saba) (juliana.saba@utdallas.edu) Lab Director: Dr. John Hansen (john.hansen@utdallas.edu) NOTE: If you have participated in experiments with the CILab at UT-Dallas or have complete this form in another format (physical or through Qualtrics), you do not need to complete this form again.
Please enter your email address:
* must provide value
Please provide your full name (first and last name):
* must provide value
Please provide your phone number:
This is required in case we need to contact you over the phone for immediate clarification or assistance regarding eligibility. * must provide value
Please indicate your preferred method of communication (you may select more than one method):
We recognize some CI/HA users have difficulty communicating over the phone and want you to communicate comfortably and confidently). * must provide value
Please provide your current address (street, city, state, and zip code):
We want to make sure the drive from your home to the CILab at UT Dallas is as local as possible. Some of our experiments will be conducted online or remotely in your home location. Before your participation date, we may need to mail study materials and equipment to your home address. * must provide value
Please indicate your sex assigned at birth:
While there are other genders and ways to identify, yours may not be included on this list. If yours is not listed, please select "Prefer Not to Anwser." We use this information when reporting demographic information regarding our study participants to our funding sponsors (National Institute of Health, NIH). * must provide value
Male
Female
Prefer Not to Answer
Male
Female
Prefer Not to Answer
As of today, what is your age?
* must provide value
Are you a native speaker of American English?
Yes
No
Are you multi-lingual? Can you speak more than one language?
Yes
No
Are you Hispanic or Latino?
We use this information when reporting demographic information regarding our study participants to our funding sponsors (National Institute of Health, NIH). * must provide value
Neither Hispanic or Latino
Hispanic
Latino
Both Hispanic and Latino
Neither Hispanic or Latino
Hispanic
Latino
Both Hispanic and Latino
Please indicate your race or ethnicity (you may select more than one anwser):
* must provide value
Alaska Native (Aleuts, Eskimos, Indians of Alaska), Alaskan
American Indian or Native American
Asian, Asian American
Biracial, multiracial, of mixed race
Black and African American
Latino/a or Latinx
Hispanic
Chicano or Chicana
Middle East, MENA, Arab Americans
Hawaiian
Pacific Islander
White
Prefer Not to Answer
Alaska Native (Aleuts, Eskimos, Indians of Alaska), Alaskan
American Indian or Native American
Asian, Asian American
Biracial, multiracial, of mixed race
Black and African American
Latino/a or Latinx
Hispanic
Chicano or Chicana
Middle East, MENA, Arab Americans
Hawaiian
Pacific Islander
White
Prefer Not to Answer
What combination of hearing aid(s)/cochlear implant(s) do you have?
* must provide value
Unilateral (cochlear implant in one ear)
Bilateral (cochlear implant in both ears)
Bimodal (hearing aid in one ear, cochlear implant in other ear)
Single (hearing aid in one ear only, unaided other ear)
Double (hearing aid in both ears)
Other combination of assistive hearing devices (BAHA, bone conduction implants, ABI, etc.)
Unilateral (cochlear implant in one ear)
Bilateral (cochlear implant in both ears)
Bimodal (hearing aid in one ear, cochlear implant in other ear)
Single (hearing aid in one ear only, unaided other ear)
Double (hearing aid in both ears)
Other combination of assistive hearing devices (BAHA, bone conduction implants, ABI, etc.)
At what age did you lose your hearing or receive a diagnosis of hearing loss?
Did your hearing impairement occur prior to or after your language development?
Pre-lingual: Born with a hearing impairment or acquired a hearing disorder and treatment/device fitting prior to language development (i.e., in childhood, or infancy). Post-lingual: Lost hearing after acquiring language skills (i.e., adulthood). * must provide value
Pre-lingual
Post-lingual
What is the etiology of your hearing loss?
The cause of your hearing loss (e.g., hereditary, disease, medication, unknown). Your audiologist may have diagnosed one of the above options. If you are unsure, or there was no diagnosis, you may enter "unknown."
After losing your hearing, was there any period where you did not wear hearing aids/implants?
Yes
No
Is your cochlear implant manufactured by Cochlear Ltd./Corporation?
* must provide value
Yes
No
I do not have a cochlear implant
Yes
No
I do not have a cochlear implant
What is the manufacturer, make, and model of your cochlear implant(s)?
For Cochlear Ltd./Corp. systems, the most popular are: CI532 Slim Modiolar, CI512 Contour Advance, CI522 Slim Straight, CI24 or CI24RE. For MED-EL or Advanced Bionics systems, information can be found online (if you do not know, someone from the CILab will follow-up with you). IMPORTANT: If you are bilateral, please provide details for both ears.If you do not have cochlear implants, please leave blank.
What is the manufacturer, make, and model of your cochlear implant sound processor(s)?
For Cochlear Corp. systems, the most popular are: Nucleus 6 (CP900, CP910, CP910), Kanso (CP950), and Nucleus 7 (CP1000), and Nucleus 8 (CP1100). For MED-EL or Advanced Bionics systems, information can be found online (if you do not know, someone from the CILab will follow-up with you). IMPORTANT: If you are bilateral, please provide details for both ears.If you do not have cochlear implants, please leave blank.
What is the manufacturer, make, and model of your hearing aid(s)?
IMPORTANT: For double hearing aids, please provide information for both devices.If you do not have hearing aids, please leave blank.
When were you implanted (month, year) for cochlear implants or when were you fitted with your first hearing aid?
IMPORTANT: If you are bilateral or bimodal, please provide dates for both ears.
Do you have a minimum of 6 months of experience with your implant device?
This question is to ensure your familiarity with the hearing sensations from your implant. * must provide value
Yes
No
For open-set sentence recognition (performed with your audiologist), do you have a minimum test score of at least 30%?
If you do not know, we can contact your audiologist on your behalf to retrieve these assessments. Yes
No
Do you have residual hearing in any or either ear, without implants of hearing aids?
Yes
No
Do you have a systemic condition which precludes the use of a cochlear implant?
Yes
No
Do you have any significant, abnormal cognitive function?
We want to make sure you are able to understand the study protocol and procedures as well as provide consent to the study protocol and procedures. Yes
No
Would you or your audiologist be able to provide the CILab with your latest MAPs or fitting specifications?
You can request the encryped file used to encode your MAPs to be sent from your audiologist to the CILab or, You can consent to us contacting your audiologist on your behalf or, You can request a copy of your MAPs and email or fax them to the CILab. Yes, I can provide them
Yes, my audiologist can provide them
No
Yes, I can provide them
Yes, my audiologist can provide them
No
Would you or your audiologist be able to provide the CILab with your speech understanding scores?
These scores are routine tests you have taken in the clinic with your audiologist. Yes, I can provide them
Yes, my audiologist can provide them
No
Yes, I can provide them
Yes, my audiologist can provide them
No
Please provide the contact information of your audiologist:
If you indicated that your audiologist can provide them, we will contact them on your behalf (copying you in the initial email correspondance in addition to your consent form). We work with a number of local audiolgists in the DFW metroplex.
Would you like to receive notifications (via email) of future participation opportunities?
Research studies are typically available three times a year (summer, spring, and fall) according to the academic calendar. You can opt-out at any time. Study details and enrollment status (enrolling, not enrolling participants) are accessible online at our website: Yes
No
