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What is your name?
   
 
 
 
Which grade level do you currently teach?
 
 
 
Do you have students in your classroom whose parents/guardians have informed you of a medically diagnosed hearing loss?
 
Yes
 
No
 
 
 
If you answered "yes" to the previous question please list the student(s) name(s):
   
 
 
 
Do you have students in your classroom whose parents have given you an audiogram or an audiological report?
   
 
 
 
If you answered "yes" to the previous question please list the student(s) name(s):
   
 
 
 
Do you have students in your classroom that wear or are supposed to wear hearing aids?
 
Yes
 
No
 
 
 
If you answered "yes" to the previous question please list the student(s) name(s):
   
 
 
 
Do you have students in your classroom that have had ear infections during the past school year?
 
Yes
 
No
 
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