We are collecting this information to help us determine if your family is eligible to participate in a study for children with hearing loss. completely confidential and will not be given to anybody outside of the Early Intervention Research Group. Do you allow the Early Intervention Research Group (EIRG) to contact you and tell you more about a research study? * must provide value
Yes No
By saying "no" to the consent form, we are not able to collect your information to see if you are eligible for this research study. Please select "yes" if you wish provide us with your information. Would you like us to contact you about future research opportunities for you and your child?* must provide value
Yes No
Today's date* must provide value
Today M-D-Y
Your first and last name* must provide value
Phone number* must provide value
Email address* must provide value
Street address* must provide value
City* must provide value
State* must provide value
Illinois
Colorado
Other (write-in)
None of the above
Illinois
Colorado
Other (write-in)
None of the above
What state?* must provide value
Zip code* must provide value
Miles away from NU location* must provide value
miles
How did you hear about the Early Intervention Research Group (EIRG)?* must provide value
Lurie Children's Hospital
Physician/Pediatrician
Early Intervention (EI) therapist or service coordinator
Therapist (private therapist, not E.I.)
Facebook group or advertisement
Instagram
Word of mouth (friend, colleague, family)
Web search (like Google)
Northwestern Clinic's Developmental Diagnostic Program (NUCASLL DDP)
Other (write-in)
Lurie Children's Hospital
Physician/Pediatrician
Early Intervention (EI) therapist or service coordinator
Therapist (private therapist, not E.I.)
Facebook group or advertisement
Instagram
Word of mouth (friend, colleague, family)
Web search (like Google)
Northwestern Clinic's Developmental Diagnostic Program (NUCASLL DDP)
Other (write-in)
What is the name of your audiologist at Lurie Children's Hospital? * must provide value
Early Intervention coordinator/therapist's name
Name of Facebook group
Who told you about EIRG?
Therapist's name
Pediatrician's name
How did you hear about us?
Do you have a child with hearing loss (or suspected hearing loss) in both ears ?* must provide value
Yes No
What's this child's name?* must provide value
______ 's gender* must provide value
Male
Female
Other (write-in)
Male
Female
Other (write-in)
Please specify * must provide value
______ 's date of birth* must provide value
M-D-Y MM-DD-YYYY
______ 's age in months View equation
What is your relationship to the child?* must provide value
Biological mother
Adopted mother
Stepmother
Biological father
Adopted father
Stepfather
Grandmother
Grandfather
Other relative (write-in)
Biological mother
Adopted mother
Stepmother
Biological father
Adopted father
Stepfather
Grandmother
Grandfather
Other relative (write-in)
What is your relationship? * must provide value
What spoken languages are used with ______ ?* must provide value
Arabic
Bengali
Chinese
English
French
German
Hindi
Japanese
Javanese
Korean
Polish
Portuguese
Russian
Spanish
Tagalog
Vietnamese
Urdu
Other (write-in)
Arabic
Bengali
Chinese
English
French
German
Hindi
Japanese
Javanese
Korean
Polish
Portuguese
Russian
Spanish
Tagalog
Vietnamese
Urdu
Other (write-in)
What other spoken language are used with ______ ?
______ 's age today View equation
How often is a language that is not English spoken with ______ ? Rarely (less than 25% of the time)
Sometimes (25-50% of the time)
Often (more than 50% of the time)
Always (100% of the time)
Rarely (less than 25% of the time)
Sometimes (25-50% of the time)
Often (more than 50% of the time)
Always (100% of the time)
Who uses a language other than English with ______ at home?* must provide value
Biological mother
Adopted mother
Stepmother
Biological father
Adopted father
Stepfather
Grandmother
Grandfather
Other relative (write-in)
Biological mother
Adopted mother
Stepmother
Biological father
Adopted father
Stepfather
Grandmother
Grandfather
Other relative (write-in)
What other person?* must provide value
Would it feel natural for you and your child to play together using mostly Spanish?
* must provide value
Yes
No
How often is a visual communication method (American Sign Language, Signed Exact English etc.) used with ______ ?* must provide value
No visual communication method used
Less than 10% of the time
10% of the time or more
No visual communication method used
Less than 10% of the time
10% of the time or more
What visual communication method is used with ______ ?* must provide value
American Sign Language (ASL) (A language that has a sign for every word and concept)
Total Communication (A combination of spoken language, American Sign Language and gestures)
Sign Supported English (SSE) (A specific approach that combines spoken language with signs that mirror English grammar)
Cued Speech (A specific approach that uses unique hand movements and placements to support the understanding of spoken language)
Other (fill in/please describe)
American Sign Language (ASL) (A language that has a sign for every word and concept)
Total Communication (A combination of spoken language, American Sign Language and gestures)
Sign Supported English (SSE) (A specific approach that combines spoken language with signs that mirror English grammar)
Cued Speech (A specific approach that uses unique hand movements and placements to support the understanding of spoken language)
Other (fill in/please describe)
Please describe* must provide value
What hearing device does ______ wear in their left ear* must provide value
No device
No device, but my child will be receiving a device
Bone conduction device (Baha, Ponto, Adhere, Bonebridge)
Hearing aid
Cochlear implant
No device
No device, but my child will be receiving a device
Bone conduction device (Baha, Ponto, Adhere, Bonebridge)
Hearing aid
Cochlear implant
What hearing device does ______ wear in their right ear* must provide value
No device
No device, but my child will be receiving a device
Bone conduction device (Baha, Ponto, Adhere, Bonebridge)
Hearing aid
Cochlear implant
No device
No device, but my child will be receiving a device
Bone conduction device (Baha, Ponto, Adhere, Bonebridge)
Hearing aid
Cochlear implant
Has it been suggested by ______ ''s audiologist that ______ use a hearing aid in one or both ears?* must provide value
Yes
No
Is ______ a candidate for cochlear implants?* must provide value
Yes
No
Maybe
Not sure
Have you been told ______ 's hearing loss was due to auditory neuropathy spectrum disorder (ANSD)?* must provide value
Yes
No
Don't know
Is ______ 's hearing loss congenital or aquired?
* must provide value
Congenital (present at birth)
Acquired (present after birth)
I'm not sure
Congenital (present at birth)
Acquired (present after birth)
I'm not sure
How old was ______ when they lost their hearing?
* must provide value
1 month old 2 months old 3 months old 4 months old 5 months old 6 months old 7 months old 8 months old 9 months old 10 months old 11 months old 12 months old 13 months old 14 months old 15 months old 16 months old 17 months old 18 months old
Please explain how ______ lost their hearing
* must provide value
Does ______ have any other condition or diagnosis that might influence his or her development? * must provide value
Yes
No
What condition or diagnosis?* must provide value
ADD/ADHD (Attention deficit disorder/Attention deficit hyperactivity disorder)
Autism Spectrum Disorder (ASD)
Blindness
Cancer
Cerebral palsy
Cleft lip/palate
Cytomegalovirus (CMV)
Down syndrome
Global developmental delay
Motor speech disorder (apraxia, dysarthria)
Seizures
Stroke
Traumatic head injury
Other diagnosis or genetic conditions (write-in)
ADD/ADHD (Attention deficit disorder/Attention deficit hyperactivity disorder)
Autism Spectrum Disorder (ASD)
Blindness
Cancer
Cerebral palsy
Cleft lip/palate
Cytomegalovirus (CMV)
Down syndrome
Global developmental delay
Motor speech disorder (apraxia, dysarthria)
Seizures
Stroke
Traumatic head injury
Other diagnosis or genetic conditions (write-in)
What has ______ been diagnosed with?* must provide value
How does this diagnosis impact your child's development (if at all), including sitting, walking, etc.?
* must provide value
Is ______ currently using a feeding tube?
* must provide value
Yes
No
* must provide value
Yes
Not yet
* must provide value
Yes
Not yet
Does ______ use gestures to communicate (reaching, pointing, waving)?* must provide value
Not yet
Yes
If yes, which gestures and for what reasons? * must provide value
This research study would involve the participation of one of ______ 's parents/caregivers. At this time, all research assessments and therapy are delivered in spoken English. However, you are able to use spoken English or visual communication with your child throughout the study. The caregiver participating in the research study must understand spoken English and use spoken English with the child the majority of the time. Which caregiver would participate with your ______ ?legal guardian . * must provide value
Biological mother
Adopted mother
Stepmother
Biological father
Adopted father
Stepfather
Grandmother
Grandfather
Other (write-in)
Biological mother
Adopted mother
Stepmother
Biological father
Adopted father
Stepfather
Grandmother
Grandfather
Other (write-in)
Who would participate? * must provide value
Does this caregiver have any hearing loss?* must provide value
Yes
No
Please explain ______ 's parent(s) hearing loss* must provide value
Does this caregiver understand spoken English?* must provide value
Yes
No
Does this caregiver use spoken English with the child at least 50% of the time or more?* must provide value
Yes
No
Please check all of the days that you are available for a 10 minute phone call to discuss study participation Monday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
Please check all of the times that you would be available on Monday for a 10 minute phone call 8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
Please check all of the times that you would be available on Tuesday for a 10 minute phone call 8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
Please check all of the times that you would be available on Wednesday for a 10 minute phone call 8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
Please check all of the times that you would be available on Thursday for a 10 minute phone call 8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
Please check all of the times that you would be available on Friday for a 10 minute phone call 8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 p.m.
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
Was the parent emailed or called and told about their eligibility? * must provide value
Not yet (pending)
Yes
No
CFC Number (Illinois Only)* must provide value
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Not applicable (not in IL)
It looks like you and your child would be eligible for a research study currently taking place at the EIRG. This research study is looking at the effects of a naturalistic communication intervention for children who are 12 months old who also have a hearing loss.
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