Database Form
Complete this form if you want to be in the CLHL Lab database. Your child can have normal hearing or hearing loss. You will be contacted only if you qualify to participate in the studies and you could decide if you want to participate. You can be removed from the database at any time by sending us an email.
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Child first name *
Child date of birth *
MM
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DD
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YYYY
Caregiver's name *
What language do you speak at home? (Check all that apply) *
Required
Does your child have a hearing loss? *
If yes, please describe the characteristics (unilateral or bilateral; mild, moderate, severe or profound):
If yes, what hearing devices does your child use?
Do you have any concerns about your child's development? If so, please explain: *
Is your child receiving any services (speech therapy, physical therapy, etc.)? If so, please explain.
If you have another child (with or without hearing loss) that may be able to participate in the studies, please describe here. We will add him/her to the database too.
How would you like to be contacted? Introduce here your phone number or email. We will just send you the opportunity to participate if your child qualifies. *
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