Wyoming Families for Hands & Voices

Untitled Document

Survey for Wyoming Parents of Children with Hearing Loss

1. How many children do you have with hearing loss?
2. What is the age of your child(ren) with hearing loss? Child 1 Child 2 Child 3 Child 4
3. Has you child(ren) ever worn hearing aids? Child 1 Child 2 Child 3 Child 4
4. How many hearing aids does your child(ren) currently wear? Child 1 Child 2 Child 3 Child 4
5. How much did each hearing aid cost? Child 1 Child 2 Child 3 Child 4
6. What sources of funding did you use to pay for the hearing aid(s)? (Check all that apply) Health Insurance Self-pay Credit card Payment Plan Borrowed money from bank Money from extended family member Medicaid/Kid Care Private foundation or agency (Please list) Other:
7. Did you use loaner hearing aids before purchasing hearing aids? Yes No
8. Since your child(ren) was diagnosed with hearing loss, how many aids have you purchased for your child(ren)? Child 1 Child 2 Child 3 Child 4
9. Did the cost of hearing aids delay your ability to get them for your child(ren)? Yes No If 'Yes' how long?
10. If cost were not an issue, would you have chosen a different hearing aid? Yes No
11. Does your child(ren) wear a cochlear implant? If 'yes' how many? Child 1 Child 2 Child 3 Child 4 No - if 'No' skip to question #15
12. What sources of funding did you use to pay for the cochlear implant(s)? (Check all that apply) Health Insurance Self-pay Credit card Payment Plan Borrowed money from bank Money from extended family member Medicaid/Kid Care Private foundation or agency (Please list) Other:
13. Did the cost of a cochlear implant delay your ability to obtain one or two for your child(ren)? Yes No If 'Yes' how long?
14. If health insurance covered the cochlear implant(s) do they also cover the upgrades? Yes No Uncertain
15. What mode of communication do(es) your child(ren) use? Spoken Language Sign Language Spoken and sign together

16. Does/did your child(ren) receive Early Intervention Services? Yes - from local Child Development Center Yes - Private provider No
17. If Early Intervention services were from a Private Provider, what sources of funding did you use to pay for the services? (Check all that apply) Health Insurance Self-pay Credit card Payment Plan Borrowed money from bank Money from extended family member Medicaid/Kid Care Private foundation or agency (Please list) Other:
18. What assistive listening devices has you child(ren) used either now or in the past? (Check all that apply) None - skip to question 22 Personal FM/Infrared at school Personal FM/Infrared at home Classroom Sound field system at school TTY or other special telephone equipment Other:
19. Estimate the total you have spent on assistive listening devices for use by all of your children. $
20. What sources of funding did you use to pay for the assistive listening device(s)? (Check all that apply) Health Insurance Self-pay Credit card Payment Plan Borrowed money from bank Money from extended family member Medicaid/Kid Care Provided by school district Private foundation or agency (Please list) Other:
21. If your child(ren) does NOT use assistive listening devices, is it because the devices are: Too expensive Not useful for my child(ren) Other:
Questions 22-25 are OPTIONAL - answers to these questions are useful in passing Hearing Aid Legislation in Wyoming.
22. Please mark your approximate family income before taxes: $1,000-$20,000 $20,001 - $40,000 $40,001 - $60,000 $60,001 - $80,000 Greater than $80,000
23. What is your ethnicity? Caucasian Hispanic Asian/Pacific Islander African-American American Indian/Alaskan Native Other/Multiracial
24. What is the primary language used in your home? English Spanish American Sigh Language Other:
25. What is the highest level of education attained by either parent? Some high school High school diploma Some college Bachelor's degree Post-graduate coursework Post-graduate degree

Do you have any additional comments related to this survey?

If you are willing to be contacted for further discussion or interested in helping with legislation, please leave your name and the best way to contact you.

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