Hello, my name is Lena DaSilva.  . I am an undergraduate Speech Language Pathology & Audiology at Northeastern University.  As part of a proposal paper concerning cochlear implants, I am conducting a survey regarding cochlear implantation. I would appreciate a response from anyone who has had cochlear implant surgery or has a child who recently had cochlear implant surgery. It is alright if you are not able to answer all of the questions below. Any response will be greatly appreciated. Thank you very much for your time.

 

1. At what age did you (your child) receive their implant?

Years

Months
2. Where is his/her hometown?

State:
 The following questions are about the last hearing aids worn before implantation.  You may need to ask your audiologist for some of these details.
Hearing Aid Manufacturer:

Model:
Hearing Aid Settings:

Output(dB):

 Max Gain:

HFA Gain:
Last ear mold, bore/tubing system?     
Did the last hearing aid provide benefit?    
Please fill in the last unaided and aided audiogram.  On the audiogram, unaided results will be circles (right ear) and X's (left ear).  The aided results will be either an "S" or and "A".
 

Test Frequency (the numbers on the top of the graph)
Test Condition 125  250 500 750 1000 1500 2000 3000 4000 6000 8000
Unaided Right (o)
Unaided Left (X)
Aided (A)
Please describe the cochlear implant program used.
Who provided the post implant rehab therapy?
How often was therapy provided? Days/week minutes/day
How many years of experience did this person have with CI's ?  

Please note that most of this information can be found in your child's  Individual Family Service Plan (IFSP) or Individualized Education Plan (IEP).

 Thanks again for your time.