Product Guidance Questionnaire

1). Your Name :

2). Your Phone Number :

3). Name of person advice is for if diff (or ref no / initials) :

4). Postcode (or town / city) :

5). Occupation of user, description of role and difficulties to address :

6). Nature of Enquiry - Personal purchase / Access to Work / DSA Enquiry / Employer Funded / Outsourcing Company / Other - please describe in detail below (**REMOVE WHAT DOES NOT APPLY)

7). Hearing instrument type - NHS Behind the ear / Private / BAHA / Cochlear Implant / No hearing aid / Other - please describe in detail below (**REMOVE WHAT DOES NOT APPLY)

8). Hearing instrument brand and model :

9). Which areas is help needed? - Telephone / General communication / Hearing in noise / Lectures & classrooms / Audio files on a PC / Meetings under 9 people / Meetings of 9 - 15 / Meetings of 15 - 25 / Meetings over 25 people / Multiple tables, / Auditoriums / Other - please describe in detail below (**REMOVE WHAT DOES NOT APPLY)

10). Wearing a hearing instrument in? Left ear only / Right ear only / Both ears / None - please describe in detail below (**REMOVE WHAT DOES NOT APPLY)

11). Which statement is most accurate? - Mainly sat at a table, desk, meeting scenario (primary transmitter on a flat surface) / mainly moving about and interacting on feet a lot (primary transmitter mainly hand held) (**REMOVE WHAT DOES NOT APPLY)

12). On site training required? Yes / No (**REMOVE WHAT DOES NOT APPLY)

13). Telephone use - Corded handset RJ9/11 / Cordless DECT handset / Corded headset RJ9/11 / Cordless headset / USB headset (Zoom / Teams etc) / Other telephone - please describe in detail below / Mobile phone use / Telephony not required) (**REMOVE WHAT DOES NOT APPLY)

14). Additional information; (please describe in more detail anything that expands on the above - REALLY USEFUL for us to easily understand what you are trying to achieve!) :




NB. Hearing instrument brand and model is usually printed on casing of hearing aid (If private aids, BAHA or Cochlear Implant please supply serial numbers)

BEFORE YOU SUBMIT THIS EMAIL.... Please ensure you supply an answer for EVERY line, if you do not think a response is required to a particular line please input N/A on that line so we know you have considered this.

The more detailed your responses the more accurate our advice will be without the need for a request for further information. Please take the time to respond fully and accurately!