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Hearing Screening Volunteer Form
First Name:
* Required
Last Name:
* Required
Employer/School/Clinic:
Mailing Address:
* Required
City:
* Required
State:
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Required
Zip:
* Required
Contact Phone Number:
* Required
Email:
* Required
Do you speak conversational Spanish?
Yes
No
Are you available to stay 7:00am to 4:00pm?
Yes
No
Are you available to stay after the fair to help clean up?
Yes
No
PLEASE INDICATE YOUR WORK AREA PREFERENCE
Tones
Yes
No
Tymps
Yes
No
OAEs
Yes
No
Open
Yes
No
PLEASE INDICATE YOUR PREVIOUS HEARING SCREENING EXPERIENCE (outside of classes)
Tones
Yes
No
Tymps
Yes
No
OAEs
Yes
No
Open
Yes
No
PLEASE INDICATE ANY PREVIOUS ACT HEALTH FAIR VOLUNTEER WORK
Tones
Yes
No
Tymps
Yes
No
OAEs
Yes
No
DO YOU HAVE ANY HEARING SCREENING EQUIPMENT AVAILABLE TO USE AT THE FAIR?
P/T Screener(s)
No
Yes: #
Otoscope(s)
No
Yes: #
Tymp Screener(s)
No
Yes: #
OAE Screener(s)
No
Yes: #
ARE YOU A
Certified Audiologist
ASU Grad Student
NON-ASU Grad Student
Undergrad Student
What is your T-Shirt size?
Medium
Large
X-Large
XX-Large
XXX-Large
NOTE: When volunteering a valid photo id will be required.