First Name:
Last Name:
Maiden Name	(if applicable)
Year of Birth:	2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959
Address:
City		State: AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip:
Email Address:	A value is required.Please use the format name@mydomain.com
Telephone:
TTY:
Occupation:

BACKGROUND INFORMATION

Cause of Hearing Loss	Age at Diagnosis
Genetic Illness Unknown Other	Birth 3-6 Months 6-9 Months 9-12 Months 12-18 Months 2 Years 3 Years 4+ Years

If other please explain:

Degree of Hearing Loss
Left Ear		Right Ear
None Mild Moderate Severe Profound		None Mild Moderate Severe Profound

Hearing technology used. Check all that apply and indicate when you began use.
LEFT SIDE					RIGHT SIDE
	Hearing Aid	Began Use				Hearing Aid	Began Use
	Cochlear Implant	Began Use				Cochlear Implant	Began Use

Primary type of communication used today None Auditory/Oral American Sign Language Total Communication

EDUCATION

	Begin	End
Years attended OHS	2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959	2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959

OHS services received

Parent/Infant

Preschool

K-3

Outreach

If mainstreamed, what grade were you mainstreamed? Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

Not mainstreamed

Primary Education (Elementary thru Jr. High)

School attended	Omaha Public Schools Millard Public Schools Bellevue Public Schools Ralston Public Schools Gretna Public Schools Blair Public Schools Elkhorn Public Schools Plattsmouth Public Schools Papillion/La Vista Public Schools Westside Public Schools Private Other
If other or Private, please specify (school, city, state)
Still attending

Please describe the services you received at this school. Check all that apply.
	Speech/Language Therapy		Classroom for Deaf/HH Children
	Interpreter		Deaf Education Itinerant Services
	Resource Room		None

Secondary Education (High School)

School attended	Omaha Public Schools Millard Public Schools Bellevue Public Schools Ralston Public Schools Gretna Public Schools Blair Public Schools Elkhorn Public Schools Plattsmouth Public Schools Papillion/La Vista Public Schools Westside Public Schools Private Other
If other or Private, please specify (school, city, state)
Still attending

Please describe the services you received at this school. Check all that apply.
	Speech/Language Therapy		Classroom for Deaf/HH Children
	Interpreter		Deaf Education Itinerant Services
	Resource Room		None
Year Graduated 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959

College

	Some College
	Two Year Community College
		Major	Year Graduated 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959
	College For the Deaf
		Major	Year Graduated 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959
	Four Year University
		Major	Year Graduated 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959

Thank you for taking the time to complete the questionnaire. We'd love to hear from you, so please tell us what you are doing now. Let us know the impact that the hearing School has made in your life. Please remember to click the button below to sned the completed survey. Thank you!