Hearing Instrument User Review - Survey 1



Please fill out and submit this form once for every hearing instrument you have used. By compiling all the responses we will be able to generate a "Consumer's Report" of sorts that can be used to compare hearing instruments. Please answer all the questions you can, estimating where exact answers are not available. The results when completed will be available at this site: http://survey.wiltontech.com

Manufacturer:
Model:
Type:
User's Name:
Owner's Hearing Characteristic :
General Description of Hearing Loss:
Left (db HTL):
	250 :
	500 :
	750 :
	1000:
	1500:
	2000:
	3000:
	4000:
	6000:
	8000:
Right (db HTL):
	250 :
	500 :
	750 :
	1000:
	1500:
	2000:
	3000:
	4000:
	6000:
	8000:
How many different instruments have you used? :
What instruments have you compared this with? :
Does the instrument have directional mikes?		Yes No
How many channels/bands?:
How many user selectable hearing programs?:
Volume Control
Was it an option?		Yes No
Did you get it?		Yes No
T-Coil
Was it an option?		Yes No
Did you get it?		Yes No
Other options chosen:
Cost (each instrument):
Ratings (1 = poorest, 7 = best)
General
Overall Construction Quality:		1 2 3 4 5 6 7
Durability:		1 2 3 4 5 6 7
Performance:		1 2 3 4 5 6 7
Feedback Stability:		1 2 3 4 5 6 7
User Mode Switching:		1 2 3 4 5 6 7
Absense of Painful Sounds:		1 2 3 4 5 6 7
Ease of Battery Replacement:		1 2 3 4 5 6 7
In Quiet Room
Sound Level Adequacy:		1 2 3 4 5 6 7
Music Sound Quality:		1 2 3 4 5 6 7
Speech Intelligibility:		1 2 3 4 5 6 7
Circuit Noise:		1 2 3 4 5 6 7
Automatic Volume Control Effectiveness:		1 2 3 4 5 6 7
Compression of Loud Sound Impulses:		1 2 3 4 5 6 7
In Noisy Room
Sound Level Adequacy:		1 2 3 4 5 6 7
Music Sound Quality:		1 2 3 4 5 6 7
Speech Intelligibility
With directional microphones:		1 2 3 4 5 6 7
Without directional microphones:		1 2 3 4 5 6 7
Circuit Noise:		1 2 3 4 5 6 7
Automatic Volume Control Effectiveness:		1 2 3 4 5 6 7
Compression of Loud Sound Impulses:		1 2 3 4 5 6 7
Room Noise Reduction:		1 2 3 4 5 6 7
Overall customer satisfaction with device:		1 2 3 4 5 6 7
Fitter Related Factors
How many fitters have you used?):
Software Knowledge
Rate fitter #1:		1 2 3 4 5 6 7
Rate fitter #2:		1 2 3 4 5 6 7
Rate fitter #3:		1 2 3 4 5 6 7
Number of visits before they made an acceptable fit:
Fitter #1:		1 2 3 4 5 to 10 10 + Never Achieved
Fitter #2:		1 2 3 4 5 to 10 10 + Never Achieved
Fitter #3:		1 2 3 4 5 to 10 10 + Never Achieved
Quality of Physical Fit:		1 2 3 4 5 6 7
Type of material (soft, hard, etc.):
Comfort:		1 2 3 4 5 6 7
Overall customer satisfaction with dispenser:		1 2 3 4 5 6 7
Did you perform self-programming?		Yes No
Cost of Programmer Equipment:
Cost of Cables:
Cost of Software:
Do you feel self-programming was worthwhile?		Yes No
Would you recommend it to others? (please comment):
Additional User Comments (Can be any length):

Required Entry: Ready to Submit Data? Yes

   

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