Applicant Hearing Form -

If you have a hearing loss, please complete and return this form so that we may better determine its extent.

Name(Required)

Birthdate (mm/dd/yyyy)(Required)

Email(Required)

1. To what extent does your hearing loss affect your sense of direction?

3. At what distance are you able to hear a person speak to you in a normal tone of voice?

4. At what distance are you able to hear a person call to you (on the street) in a relatively loud voice?

Applicant Hearing Form