Hearing Health of Children Born Between 2020-2021 Question Title * 1. Is your child... Male Female Rather not say Question Title * 2. When is your child's birthday? Date / Time Date Time AM/PM - AM PM Question Title * 3. At how many weeks was your child born (gestational age)? Question Title * 4. Was the delivery vaginal or cesarean? Vaginal Cesarean (C-Section) Question Title * 5. Which hospital did you deliver at? Question Title * 6. How long was your postpartum stay at the hospital before being discharged? 1 night 2 nights 3 nights 4 nights Over 4 nights Not Sure Other (please specify) Question Title * 7. Did the COVID-19 pandemic cause you to shorten your postpartum hospital stay? Yes, there was a lack of hospital beds Yes, I wanted to go home earlier in hopes of not catching COVID-19 Yes, there was a lack of hospital staff Yes, I wasn't allowed any visitors No Not sure Other (please specify) Question Title * 8. Did your child stay in the NICU? Yes No If yes, what was the reason & how many days/ weeks/ months did they stay? Question Title * 9. Did your child receive a hearing screen prior to discharge from the hospital? Yes No Not Sure Other (please specify) Question Title * 10. If your child received a hearing screen prior to discharge, do you remember when exactly the test was done? In the first 24 hours after birth After 24 hours, but before my child was 48 hours old After 48 hours After 3 days After 4 days Not sure, don't remember Not sure, my child received the hearing test during their NICU stay N/A, my child did not receive a hearing screen in the hospital prior to discharge Other (please specify) Question Title * 11. Do you know if your child was screened with otoacoustic emissions (OAEs) or with an auditory brainstem response (ABR)?OAE = microphone is inserted into the earABR = stickers/ electrodes are placed on the child’s forehead & behind the ears OAE ABR Not Sure N/A, my child did not receive a hearing screen Other (please specify) Question Title * 12. Did your child fail their initial hearing screen & need follow-up testing? No, my child passed their hearing test Yes, my child failed the right ear Yes, my child failed the left ear Yes, my child failed both ears N/A, my child did not receive a hearing screen Other (please specify) None of the above Question Title * 13. If your child failed their hearing test at the hospital, how long after their birth did they receive follow-up testing? 1 week 2 weeks 3 weeks 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months 12-18 months 18-24 months 24-30 months 30-36 months Not sure, don't remember N/A my child passed their screen at the hospital N/A, never went for follow-up testing N/A, my child did not receive a hearing screen Other (please specify) Question Title * 14. Did the COVID-19 pandemic/ lockdown restrictions cause you to delay follow-up testing? No, I followed up right away Yes, I did not want to travel during the pandemic Yes, there was no outpatient appointment availability Yes, my appointment was canceled N/A my child passed their screen at the hospital N/A, my child never went for follow-up testing after their initial screen N/A, my child did not receive a hearing screen Other (please specify) Question Title * 15. Was your child diagnosed with hearing loss? No, my child passed their follow-up test Yes, my child has hearing loss in both ears Yes, my child has hearing loss in the left ear Yes, my child has hearing loss in the right ear No, my child passed their initial hearing screen at the hospital Not sure, never went for follow-up testing N/A, my child did not receive a hearing screen Other (please specify) Question Title * 16. How long after birth was your child diagnosed with hearing loss? 1 week 2 weeks 3 weeks 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months 12-18 months 18-24 months 24-30 months 30-36 months Not sure, don't remember N/A, my child never went for follow-up testing N/A, my child does not have hearing loss N/A, my child never received a hearing screen Other (please specify) Question Title * 17. What is the degree of your child's hearing loss? Mild Moderate Moderate-Severe Severe Profound Unknown N/A, never went for follow-up testing N/A, my child was not diagnosed with hearing loss Other (please specify) Question Title * 18. Does your child use an amplification device (ex: hearing aid, BAHA, cochlear implant) or other assistive technology? Yes, my child uses a hearing aid Yes, my child has a cochlear implant Yes, my child has a bone-anchored hearing aid (BAHA) Yes, my child utilizes an FM system Yes, my child uses a combination of the above N/A, my child never went for follow-up testing N/A, my child does not have hearing loss Other (please specify) Question Title * 19. How long after your child’s hearing loss diagnosis did you receive intervention services? 1 week 2 weeks 3 weeks 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months 12-18 months 18-24 months 24-30 months 30-36 months Not sure, don't remember N/A, my child never went to a follow-up appointment after their diagnosis N/A, my child never received a hearing screen N/A, my child was not diagnosed with hearing loss Other (please specify) Question Title * 20. Did the COVID-19 pandemic delay the time it took for your child to receive intervention services for their hearing loss? Yes, I did not want to travel during the pandemic Yes, there was no outpatient appointment availability Yes, my appointment was canceled No, my child received intervention rather quickly N/A, my child was not diagnosed with hearing loss N/A, my child never went to a follow-up appointment N/A, my child never received a hearing screen Other (please specify) Question Title * 21. When did your child start saying words? Earlier than 12 months 12 months 12-18 months 18-24 months 2.5 years old 3 years old 3.5 years old 4 years old My child is nonverbal Question Title * 22. How many words does your child say? Less than 50 50-100 100-200 Over 200 Over 300 Over 400 500+ words My child is nonverbal Question Title * 23. Is your child able to form sentences? Yes No Sometimes My child is nonverbal Question Title * 24. Is your child’s articulation clear & understandable to most people? Yes No Sometimes My child is nonverbal Question Title * 25. Does your child receive speech therapy services? Yes No If yes, please say how many times per week & when they started this service Question Title * 26. Did the COVID-19 pandemic delay the time it took for your child to receive speech therapy services? Yes, there was a shortage of speech language pathologists Yes, there were no appointments available No, my child received services pretty quickly N/A, my child does not receive speech therapy Other (please specify) Question Title * 27. Do you have any concerns for how your child is developing? Yes No If yes, please explain Question Title * 28. When was the last time your child received a hearing test/ screen? Less than 6 months ago 6 months to 1 year ago 1 to 2 years ago 2.5 years ago 3 years ago 3.5 years ago 4 years ago Not sure Not since the hospital when they were born N/A, my child never received a hearing screen Done