10-10128 Audiology Hearing Aid Questionaire

OMB Number 2900-0770

Estimated Burden: 5 mins

EXP Date: XX/XX/2014

Audiology and Speech Pathology Service

Outcome Measures Questionnaire IOI-HA

OMB 2900-0770

Estimated burden: 5 minutes

Expiration Date xx/xx/xxxx

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average five (5) minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Form 10-10128

Name (please print):   ___________________________________________ Last 4 of SSN:   __ __ __ __

Completion date (mm/dd/yy):   __________________ Method of entry: Return Mail

Please select the best answer to each question in regards to your most recently issued hearing aids.

1.  Think about how much you used your present hearing aid(s) over the last two weeks. On an average day, how many hours did you use the hearing aid(s)?

None Less than 1 hour 1 to 4 hours 4-8 hours More than 8 hours

per day per day per day per day

2.  Think about the situation where you most wanted to hear better, before you got your present hearing aid(s). Over the past two weeks, how much has the hearing aid helped in those situations?

Not at all Slightly Moderately Quite a lot Very much

3.  Think again about the situation where you most wanted to hear better. When you use your present hearing aid(s), how much difficulty do you still have in that situation?

Very much Quite a lot Moderate Slight None

4.  Considering everything, do you think your present hearing aid(s) is worth the trouble?

Not at all Slightly Moderately Quite a lot Very much

5.  Over the past two weeks, with your present hearing aid(s), how much have your hearing difficulties affected the things you can do?

Very much Quite a lot Moderate Slightly None

6.  Over the past two weeks, with your present hearing aid(s), how much do you think other people were bothered by your hearing difficulties?

Very much Quite a lot Moderate Slightly None

7.  Considering everything, how much has your present hearing aid(s) changed your enjoyment?

Worse Not at all Slightly Better Quite a lot better Very much better

8.  How much hearing difficulty do you have when you are not wearing a hearing aid?

Severe Moderately severe Moderate Mild None

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