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hear
[p. 82]

HEARING SUPPLEMENT

R1

[] No Hearing Problem (NP)
[] A, B, or 33 in C2 (1-3)

1. Has -- ever used a hearing aid?

1 [] Y
2 [] N


(Hand Card H)
CARD H
Which statement best describes your hearing in your left ear (without a hearing aid)?

1. Hearing is good
2. Little trouble hearing
3. Lot of trouble hearing
4. Deaf


Which statement best describes the hearing in your right ear (without a hearing aid)?

1. Hearing is good
2. Little trouble hearing
3. Lot of trouble hearing
4. Deaf

Please look at this card-


2a. Which statement best describes --'s hearing in his LEFT ear (without a hearing aid)?

1 [] Good
2 [] Little trouble
3 [] Lot of trouble
4 [] Deaf


b. Which statement best describes --'s hearing in his RIGHT ear (without a hearing aid)?

1 [] Good
2 [] Little trouble
3 [] Lot of trouble
4 [] Deaf

If age 3+, ask:

3a. (Without a hearing aid) Can -- usually HEAR AND UNDERSTAND what a person says without seeing his face if that person WHISPERS to him from across a quiet room?

[] Under 3 (R2)
1 [] Y (R2)
2 [] N


b. (Without a hearing aid) Can -- usually HEAR AND UNDERSTAND what a person says without seeing his face if that person TALKS IN A NORMAL VOICE to him from across a quiet room?

1 [] Y (R2)
2 [] N


c. (Without a hearing aid) Can -- usually HEAR AND UNDERSTAND what a person says without seeing his face if that person SHOUTS to him from across a quiet room?

1 [] Y (R2)
2 [] N


d. (Without a hearing aid) Can -- usually HEAR AND UNDERSTAND a person if that person SPEAKE LOUDLY into his better ear?

1 [] Y (R2)
2 [] N


e. (Without a hearing aid) Can -- usually tell the sound of speech from other sounds and noises?

1 [] Y (R2)
2 [] N


f. (Without a hearing aid) Can -- usually tell one kind of noise from another?

1 [] Y (R2)
2 [] N


g. (Without a hearing aid) Can -- hear loud noises?

1 [] Y
2 [] N

R2
Q.'s 1-3
For persons 17 years old or over, show who responded for (or was present during the asking of) Q.'s 1-3. If persons responded for self, show whether entirely or partly. For persons under 17, show who responded for them.

1 [] Responded for self-entirely
2 [] Responded for self-partly
Person ____was respondent
[p. 83]


[MK Note: Page 83 contains a response sheet for questions asked on page 82. The response sheet has five columns in which to enter responses; only one is represented here since each column contains identical information.]

R1

[] No Hearing Problem (NP)
[] A, B, or 33 in C2 (1-3)
1.

1 [] Y
2 [] N

2a.

1 [] Good
2 [] Little trouble
3 [] Lot of trouble
4 [] Deaf

b.

1 [] Good
2 [] Little trouble
3 [] Lot of trouble
4 [] Deaf

3a.

[] Under 3 (R2)
1 [] Y (R2)
2 [] N

b.

1 [] Y (R2)
2 [] N

c.

1 [] Y (R2)
2 [] N

d.

1 [] Y (R2)
2 [] N

e.

1 [] Y (R2)
2 [] N

f.

1 [] Y (R2)
2 [] N

g.

1 [] Y
2 [] N

R2

1 [] Responded for self-entirely
2 [] Responded for self-partly
Person ____ was respondent