INCUS Project: Scoping Survey

Question Title

* 1. Please tell us a little bit about yourself so we can understand how we reflect the diversity of our community. Which age range do you fall into?

Question Title

* 2. Are you:

Male

Female

Prefer not to say

Question Title

* 3. Occupation (or previous if retired)

Question Title

* 4. Do you have a hearing loss?

Yes

No

Maybe

Question Title

* 5. Do you know of anyone with a hearing loss?

In a professional capacity

In a personal capacity

No

Question Title

* 6. What do you believe are the most important challenges for someone with hearing loss in everyday life?

Question Title

* 7. On a scale from 1 to 5, how important is it to be deaf aware for the following organisations: (1 least important, 5 very important)

	1	2	3	4	5
GP Surgeries	GP Surgeries 1	GP Surgeries 2	GP Surgeries 3	GP Surgeries 4	GP Surgeries 5
Banks	Banks 1	Banks 2	Banks 3	Banks 4	Banks 5
Audiologists	Audiologists 1	Audiologists 2	Audiologists 3	Audiologists 4	Audiologists 5
Leisure Clubs	Leisure Clubs 1	Leisure Clubs 2	Leisure Clubs 3	Leisure Clubs 4	Leisure Clubs 5
Pharmacies	Pharmacies 1	Pharmacies 2	Pharmacies 3	Pharmacies 4	Pharmacies 5
Restaurants	Restaurants 1	Restaurants 2	Restaurants 3	Restaurants 4	Restaurants 5
Residential Homes	Residential Homes 1	Residential Homes 2	Residential Homes 3	Residential Homes 4	Residential Homes 5
Grocery Shops	Grocery Shops 1	Grocery Shops 2	Grocery Shops 3	Grocery Shops 4	Grocery Shops 5
Clothes Shops	Clothes Shops 1	Clothes Shops 2	Clothes Shops 3	Clothes Shops 4	Clothes Shops 5
Educational Settings	Educational Settings 1	Educational Settings 2	Educational Settings 3	Educational Settings 4	Educational Settings 5
Emergency Services	Emergency Services 1	Emergency Services 2	Emergency Services 3	Emergency Services 4	Emergency Services 5

Question Title

* 8. Do you think an accreditation scheme for local businesses eg. Incus project would be useful? Please explain your answer.

Yes

No

Question Title

* 9. Do you think organisations would pay to join this scheme? Please explain why.

Yes

No

Question Title

* 10. Do you think organisations should pay to join this scheme? Please explain why.

Yes

No

Question Title

* 11. If you would you be happy to be contacted with further questionnaires regarding specific experiences, please enter your details below, or skip to the final question.

Name

Company

Address

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 12. Please share any other comments you have below: