Census of the Deaf and Hard of Hearing

Please provide the following information:

First Name	Required
Middle Name
Last Name	Required
Street address	Required
Address (cont.)
City	Required
County	Select a County....... BARBOUR BERKELEY BOONE BRAXTON BROOKE CABELL CALHOUN CLAY DODDRIDGE FAYETTE GILMER GRANT GREENBRIER HAMPSHIRE HANCOCK HARDY HARRISON JACKSON JEFFERSON KANAWHA LEWIS LINCOLN LOGAN MARION MARSHALL MASON MERCER MINERAL MINGO MONONGALIA MONROE MORGAN MCDOWELL NICHOLAS OHIO PENDLETON PLEASANTS POCAHONTAS PRESTON PUTNAM RALEIGH RANDOLPH RITCHIE ROANE SUMMERS TAYLOR TUCKER TYLER UPSHUR WAYNE WEBSTER WETZEL WIRT WOOD WYOMING Required
Zip/Postal code	Required     Format 99999-9999
Work Phone	Format (304)999-9999
Home Phone	Format (304)999-9999
E-mail

Education highest completed:

Select from list . . . Have not completed GED or Diploma Bachelor's Degree Master's Degree Doctorate Degree Required

School(s) Graduated:

Year of Graduation:

Current Job Title:

Type of Hearing Loss:

(Click one.. ) Required
Both ears (Bi-lateral)
One ear (Unilateral)

(Click One.. ) Required
Conductive
Sensorineural
Mixed

Age of Onset:

Select from list.... Birth Pre-lingual (before language) Post-lingual (after language) Required

Specify Age if Onset was after Birth: 

Degree of Hearing Loss (in the better ear):

Select from list . . . Normal 25-40 dB Mild Hearing Loss 41-55 dB Moderate Hearing Loss 56-70 dB Moderately Severe Hearing Loss 71-90 dB Severe Hearing Loss 91 dB plus Profound Hearing Loss Fluctuating Hearing Loss Required

Choose one of the following options:

Select from list . . . Unknown Heredity Rubella (1963 - 1965) Drug Toxic to Auditory System High Fever Aging Birth Trauma Head Trauma Prematurity Rh Incompatibility Noise Exposure Otosclerosis Cytomegalovirus Infection Waardensburg Syndrome Respiratory Distrees Syndrome Fetal Alcohol Syndrome Usher's Syndrome Spinal Meningitis Other Required

What kind of assistive devices do you use:

Hearing Aid(s)	TTY
Cochlear Implant	Real Time Captioning
Phone Amplications	Other
None

 

Would you like to be on our mailing list to receive the Commission newsletters, announcements, and so forth?

Yes
No