"I recently ordered the motorola neck loop. (Shush) I do not LIKE it at all! TOO BIG AND TOO BULKY. And the neck loop part kept coming off every time I turn my neck. I am taking this one back and (ordering HATIS)."
name withheld by request
8/28/2003

Hearing Dogs for Deaf People New Zealand

Help us support
'Hearing Dogs'
As our sales grow, so will our contribution to 'Hearing Dogs' services.

Would you like Claritasconnect to help you in choosing the right headset?

Please note that information herein will not be sold, nor shared with any third party. You are under no obligation to complete this, however it will greatly enhance our present and future ability to help you, and meet your needs as best we can. We do respect your privacy, however for us to respond to your enquiry, and help you choose the right product/s to meet your unique needs, certain information is critical to that process. Please complete this form as much as possible, especially those items marked with an ** (asterisk).

******Name:

Clinic name:

Institutional name:

**Address:

**Country:

**Zip or postal code:

**Phone:

Mobile:

Fax:

**E-mail:

**1. Are you inquiring for yourself or for another?:

Yes
No - If another, what is your relationship to them?

**2. Using technology - how would you describe your hearing loss?

With hearing aids
Without hearing aids If 'without hearing aids' is checked, go to question 4.

Aided Right
Aided Left

BTE
ITE

Analogue
Digital

Brand name(s):
**T/Coil? Yes No C.I. - If so, what brand?

3. How long have you worn a hearing aid(s) for?

Months
Years
C.I./ Other - If so, how long?

4. List existing assistive listening or communication devices used (if any).

Past:
Present:

Are you satisfied with these?
Yes
No
If not, please explain in what way your needs are not being met at present:

**5. Do you have a hearing care professional with whom you are in regular attendance?

Audiologist
Hearing Therapist
Audiometrist
Other
None

**6. Describe the professional or primary use for your headset:

**7. Describe your critical environmental situations (i.e. for work, home, school, other):

Noisy
Quiet
Internal
External
Traveling by Car
Traveling by Air
Public places
Private

Other e.g. seminars or conferences:

**8. How many hours per day do you need to be available for telephone use?

Landline:
Cordless:
Mobile:
Other: (multi-media):

**9. What brand/model telephones will you be using with HATIS?

Landline:
Cordless:
Mobile:	CDMA GSM TRIBAND
Other:

**10. Do you need a rerecommendation to change/choose a new phone?

Yes
No

**11. Identify your current interest in hearing (better) using a variety of consumer electronics:

CD/DVD
Walkman/radio/TV
Multi-media/Internet telephony
Airline headsets
Other If other, please state?

**12. What would you describe as your greatest hearing challenge and does it stand significantly in the way of achieving your objectives or enhancing your life?

Comment:

13. In a perfect world, what would you like a Hatis headset to achieve most for you?

Comment:

14. Do you experience stress/fatigue/tinnitus which you believe is directly associated with your hearing impairment?

Comment:

15. Do you consider yourself to be a "reluctant" communicator by telephone?
Do you find telephone calls stressful - something to be "got over with quickly"?

Comment:

16. Do you use other skills/behaviors ie texting with a mobile phone?

Explain:

17. When using voice mail, do you have difficulty clearly understanding?

Yes
No

Comment:

18. How important is better comprehension of numbers, letters, and foreign accents to you?

Very
Not very
Not applicable

Comment:

**19. Who will be paying for your Hatis headset?

Self
Employer
ACC/Workbridge/State assistance
Insurance
Voluntary organization
Other

**20. Who will be paying for your Epic headset?

Self
Employer
Other

21. What additional resources would you like to see on the website www.ihear.co.nz?

Comment:

22. What search criteria, or other resources did you use to find us?

Comment:

23. Is there anything else you would like to tell me today?