| 1. The highest education level my mother achieved is: |
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| 2. The highest education level my father achieved is: |
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| 3. My mother earns: |
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| 4. My father earns: |
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| 5. English is hard for me: |
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| 6. Using sign language is hard for me: |
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| 7. Lipreading/Speechreading is hard for me: |
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| 8. People understand me most of the time when I speak: |
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| 9. I live: |
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| 10. I am from which country: |
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| 11. I heard about this survey from: |
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| 12. If you heard about this survey from a website, what website was it? |
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| 13. I was born in the year: |
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| 14. I am: |
American Indian or Alaskan Native
Asian
Black
Native Hawaiian or Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
White
Other
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| 15. I identify as: |
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| 16. From 0 (a little important to me) to 5 (very important to me) I feel my identity is: |
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| 17. My mother identifies as: |
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| 18. My mother is: |
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| 19. My father identifies as: |
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| 20. My father is: |
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| 21. My deafness is ____ for my family to accept: |
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| 22. Deafness has negatively affected my ability to get or keep a job: |
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| 23. Deafness has negatively affected my ability to benefit from my education: |
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| 24. The language I learned first is: |
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| 25. If neither English nor ASL is my first language, then my first language is: |
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| 26. The language I use most often now is: |
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| 27. If neither English nor ASL is the language I use most often now, then the language is: |
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| 28. My education experience as a child is best described as: |
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| 29. If I had hearing aids before, I liked them: |
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| 30. I am: |
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| 31. I feel comfortable in the hearing community: |
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| 32. I feel comfortable in the Deaf world: |
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| 33. How many people live in my household? |
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| 34. How many children/dependents do I have? |
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| 35. I live in: |
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| 36. On a scale of zero (least happy) to ten (most happy), right now I feel: |
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| 37. On a scale of zero (least happy) to ten (most happy), for most of my life I have felt: |
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| 38. I am: |
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| 39. My highest educational level is: |
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| 40. I earn: |
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| 41. My primary job best fits which category: |
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| 42. My high school GPA is: |
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| 43. My college GPA is: |
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| 44. After graduating from high school or college, it took me ____ to find a job: |
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| 45. I feel that cochlear implants are: |
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| 46. The year I first entered high school (0000 if I didn't go to high school): |
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| 47. The year I first entered college (0000 if I didn't go to college): |
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| 48. The year I graduated from high school (0000 if didn't graduate): |
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| 49. The year I graduated college (0000 if didn't graduate): |
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| 50. My favorite subject in high school was: |
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| 51. My major in college is/was: |
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| 52. If I work, there are ____ deaf/hard of hearing people at my workplace: |
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| 53. If I work, I work ____ hours per week (0 if don't work): |
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| 54. My work income is: |
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| 55. I am paid fairly and not less because I'm d/Deaf: |
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| 56. I receive government disability benefits or support from the government: |
Yes, I collect SSDI
Yes, I collect SSI
Yes, I have DOR (Formerly VR)
Yes, I get SSI and SSDI
Yes, I collect SDI (State Disability)
Yes, I get another benefit
No, I receive no support
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| 57. I am: |
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| 58. For college, I attended: |
Did not go to college
A first-tier university (first-tier university list)
CSUN
Gallaudet
Rochester Institutute of Technology (without NTID)
Rochester Institute of Technology (with NTID)
Other
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| 59. I have received ___ job promotions in the past five years: |
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| 66. How much would I be willing to pay to keep implants for other people (negative number if I want to pay to get rid of implants): |
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| 67. With my hearing aid, I can: |
Did not use hearing aid
Be aware of sounds around me
Hear my voice/voice of others
Understand a few sounds and words
Understand patterns of speech (short vs long sounds, loud vs quiet sounds, questions vs statements)
Understand a few words when aware of the topic
Understand many words in most situations
Understand sentences with almost no problem (and no lipreading)
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| 68. Without any technology, I can hear: |
Nothing
Be aware of sounds around me
Hear my voice/voice of others
Understand a few sounds and words
Understand patterns of speech (short vs long sounds, loud vs quiet sounds, questions vs statements)
Understand a few words when aware of the topic
Understand many words in most situations
Understand sentences with almost no problem (and no lipreading)
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| 69. With the telephone, I can: |
Recognize a busy signal on the telephone
Recognize a voice on the telephone
Able to use the telephone for basic conversation
Able to use the telephone normally
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| 70. Why wouldn't I get the implant? |
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| 71. My deafness has improved the quality of my life: |
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| 72. On a scale of 0 (not valuable) to 10 (very valuable) the Cochlear Implant is worth a lot of money to me: |
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| 73. I interact with hearing people ____: |
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| 74. Hearing people don't understand that I am deaf: |
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| 75. How deafness implant helps me with my social, family, and working lives: |
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| 76. I like being deaf most in these situations: |
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| 77. I don't like being deaf in these situations: |
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| 78. In general, my life has changed in this way, with my deafness |
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