AgDARE - Agricultural Disability Awareness and Risk Education

Hearing Loss - "Sound Advice throughout the Years" Answer Sheet/Questionnaire

Student Identification Record for Sound Advice throughout the Years

Please fill out this form before you proceed. Leave it attached to this document.

Print your first name in this box.	Print your last name in this box.
Write your instructor’s last name in the box at the right.
Write the name of your university in the box at the right.
Write today’s date in the box at the right.

Thank you.

Answer Sheet

As you read the problem booklet, circle your answer to each question on this answer sheet. Please don't write in the problem booklet. That way the problem booklets can be reused.

Circle a T or F in front of each answer number that appears in the problem booklet.

Question A	Question B	Question C	Question D
T    F    1.	T    F    8.	T    F    13.	T    F    18.
T    F    2.	T    F    9.	T    F    14.	T    F    19.
T    F    3.	T    F    10.	T    F    15.	T    F    20.
T    F    4.	T    F    11.	T    F    16.	T    F    21.
T    F    5.	T    F    12.	T    F    17.	T    F    22.
T    F    6.			T    F    23.
T    F    7.			T    F    24.
			T    F    25.
			T    F    26.

Please complete the questionnaire below. Thanks!

Questionnaire

1) Name of exercise: Sound Advice throughout the Years

2) Your age? ______

3) Your sex? ____ M ____ F

4) Do you work on a farm? ____ Yes ____ No

5) Size of farm (acres) _______

6) Do you work around loud equipment like tractors, chainsaws, etc.? ____ Yes ____ No

7) About how many hours each week do you work around loud noise like that made by tractors, chainsaws, silo blowers and other machinery? _______ hours

8) Are you exposed to other non-farming loud noises like motorcycles, ATVs, loud music, machinery and other loud noise such as: (Please list) ____ Yes ____ No

_______________________________________________________________________________

9) About how many hours each week are you around loud noises like those listed in item 8? _______ hours

10) Please rate how well you can hear quiet sounds and quiet conversation while talking to a person in a crowded room with lots of other background noise. (check only one item)
____ Can't hear ___ Have trouble hearing ___ Can hear pretty well ___ Can hear very well

11) After being around loud noise do your ears ever ring or feel stuffy?____ Yes ____ No

12) About how long do your ears ring or feel stuffy after you are around loud noise? _______ hours

13) Do you ever wear hearing protectors when you are around loud noise? ____ Yes ____ No

14) If “Yes” to item 13, what type of hearing protectors do you wear? ___ Plugs ___ Muffs

15) If “Yes” to item 13, out of every 10 times you are around loud noise, how many times do you wear hearing protectors? (circle one number )

Never

0

1

2

3

4

5

6

7

8

9

10

Always

Now think about the story you just finished. Circle the number that tells how much you agree or disagree with the following statements.

Statement		Strongly Disagree			Strongly Agree
16)	The situation described in this exercise could happen to me.	1	2	3	4
17)	This exercise taught me how to prevent hearing loss.	1	2	3	4
18)	Wearing hearing protectors while being around loud noise can prevent hearing loss.	1	2	3	4
19)	People who are around loud noise should make sure they have hearing protectors available (ear plugs or ear muffs).	1	2	3	4
20)	Because of this exercise, I will wear hearing protectors when I am around loud noise.	1	2	3	4
21)	The exercise took too long to complete.	1	2	3	4
22)	I liked doing the exercise.	1	2	3	4
23)	The written directions in the exercise were clear.	1	2	3	4
24)	The exercise drawings were easy to understand.	1	2	3	4
25)	The information in the answer key was accurate and helpful.	1	2	3	4
26)	The exercise story is easy to read.	1	2	3	4
27)	I had a chance to discuss the activity and share my ideas.	1	2	3	4
28)	Because of this exercise I know what to do to protect my hearing.	1	2	3	4
29)	Because of this exercise I will encourage other people to wear hearing protectors when they are around loud noise.	1	2	3	4
30)	I know where to find and purchase earplugs to protect my hearing.	1	2	3	4

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