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Name: |
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Address: |
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City: |
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State:(if in
US): |
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Zip: |
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Age: |
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Gender: |
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Occupation: |
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E-Mail Address: |
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Business Phone
(with area
code): |
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Home Phone
(with area
code): |
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Are you: |
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If Other: |
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Is your hearing loss:
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Do you wear hearing
aids? |
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Right Ear: |
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If Other: |
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Left Ear: |
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If Other: |
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What Make and
Model? |
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How long have you worn hearing
aids? |
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How long have you worn your
current hearing aid? |
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How well do you understand in
noise with your aids? |
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Are you able to understand
speech over the telephone with your hearing aids?
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Without hearing aids?
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Are you aware of cochlear
implant technology? |
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Do you have a cochlear implant?
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Experience With Counter System
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Did you try the Audex
Amplified/t-coil compatible counter system? |
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At gate number: |
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| Please rate its: |
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Effectiveness: |
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Ease of use: |
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Availability: |
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Will you use this system when
you are at the airport? |
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Should such systems be available
at all airports? |
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Airport Experiences & Options
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| Do you have difficulty hearing at airport...
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Ticket Counters:
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Gate Counters: |
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Restaurants: |
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News Stands: |
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Announcements in gate areas:
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TV in Gate/waiting areas:
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During boarding:
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In flight: |
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| Admiral's Club: |
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Information Counter:
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TV area: |
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Bar Area: |
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Other: |
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As an airline traveler which
three areas above would you most like to see made more hearing
accessable? |
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Comments: |
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This study is
expected to continue for six to twelve months. Other studies
are planned in other areas of transportation and
communication. Would you like to receive information about
these studies and how you can participate? |
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Would you like to
receive information about the results of this study and what
devices will be available to improve your ability to
communicate in noisy environments? |
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Would you like to
know more about the sponsors of this study and what they are
doing to improve understanding of speech in noise?
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I understand that the Audex/American Airlines
Hearing Study is a limited time program. This program will be
done to benefit the hearing impaired from the information
gathered. This information will not be used in any way by
parties other than those who administer it ( Audex and
American Airlines). Other standard warnings from non-secured
Internet message transmissions apply as per any E-mail
systems. Again, the information offered by the respondents of
this program will be held in strictest
confidence. |
| I agree with the
conditions: |
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Call us at 800-237-0716 for
more information, or E-mail us sales@audex.com |
