Please help with this survey

[Jennifer Lantz, MS, CFY/A]

If everyone could please take a minute and fill out this survey, I would 
TRULY appreciate it!  Thanks.

Jennifer

					Ototoxicity Survey

	Please respond via email to 
Jenn.the.audiologist at worldnet.att.net, 
	or mail to 3502 9th St Suite 410, Lubbock, TX 79415 Attention: 
Jennifer Lantz,
	or fax to (806)743-1357 Attention: Jennifer Lantz.

1. What is your primary work setting?
	a. hospital clinic	d. school	g. other _________
	b. physician's office	e. university		
	c. private practice	f. military

2. What is your primary responsibility?
	a. clinical audiology		d. dispensing hearing aids	
g. administration
	b. educational audiology 	e. industrial audiology
	c. research			f. teaching/supervising graduate 
students

3. How many audiologists are employed in your office/clinic?  _______

4. Do you have an ototoxicity program in place? If no, please skip to 
question 17.
	a. yes
	b. no, but are in planning stages
	c. no, and we have no plans to begin one

5. Who is in charge of your ototoxicity monitoring program?
	a. audiologist
	b. physician
	c. audiologist and physician
	d. other ____________

6.Who is your primary source of referrals for your ototoxicity 
monitoring program?
	a. Specialist physician		
	b. General practice physician 
	c. Other _______________
  
7.Who are your secondary sources of referrals for your ototoxicity 
monitoring program
(circle all that apply)?
	a. Specialist physician		
	b. General practice physician 
	c. Other _______________
 
8. For which patients do you perform monitoring (circle all that apply)?
	a. Cancer			d. Neonatal intensive care
	b. Surgical intensive care	e. unsure
	c. Pediatric intensive care

9. What CPT code(s) do you use for billing purposes for your ototoxicity 
monitoring
patients? ___________________________________________________

10. Please indicate the brand and model of equipment you use in your 
ototoxicity
monitoring program (e.g. Grason-Stadler GSI-61 with high frequency 
option).
__________________________________________________________

11. Which frequencies do you test (circle all that apply)?
	a. 250 Hz	f. 2000 Hz	k. 10,000 Hz
	b. 500 Hz	g. 3000 Hz	l. 20,000 Hz
	c. 750 Hz	h. 4000 Hz	m. other (please specify) 
_________
	d. 1000 Hz  	i. 6000 Hz	     __________________________
	e. 1500 Hz	j. 8000 Hz

12. When do you monitor the patients (e.g. baseline before treatment, 
specific increments
during treatment, specific increments post treatment)? 
___________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

13. Please briefly describe your criteria for a significant change in 
the audiogram.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

14. Do you have access to the patient's complete records (e.g. the type 
of drug and
dosage)?
	a. yes
	b. no, only the audiological information

15. Are the monitoring results given to the patient's physician?
	a. yes
	b. no

16. Does the physician alter the patient's treatment (dosage OR drug) 
based on the results
of the ototoxicity monitoring?
	a. yes
	b. only in conjuction with peak and trough information
	c. no
	d. unsure

17. Does your office/clinic dispense hearing aids?
	a. yes
	b. no

Thank you for taking the time to answer these questions. Please contact 
me if you are
interested in the results.