Pre-Test Survey


Direct Visual Signaling as a Means for Occupant Notification in Large Spaces

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Text Box: Participant # assigned for use in reports.
Participant Survey Pre-Test

(To be completed after reading and signing the Participant Information Sheet & Consent Form.)

 

 

Name: ___________________________________________________ Age:_______

Address: ___________________ City: _____________________  ST:_______ Zip: ____________

Contact Phone #:________________________ email:_____________________________________

 

 

 

Circle One

1.

Have you participated in other tests of fire alarm strobe light effectiveness?

Yes

No

2.

Do you have a hearing impairment?  (If No, skip to Question 3.)

Yes

No

 

If you have a hearing impairment, has it been evaluated by trained medical personnel (doctor, audiologist, etc.)?

Yes

No

 

In general, what is the severity of your hearing impairment:

 

 

 

Mild

Moderate

Severe

Total (Deaf)

 

 

3.

Do you have a vision impairment?  (If No, skip to Question 4.)

Yes

No

 

If you have a vision impairment, has it been evaluated by trained medical personnel (doctor, optomologist, etc.)?

Yes

No

 

In general, what is the severity of your vision impairment:

 

 

 

Mild

Moderate

Severe

Total (Blind)

 

 

 

Are you wearing corrective glasses or contact lenses?

Yes

No

4.

Do you have any form of epilepsy?

Yes

No

5.

Have you ever had a seizure?

Yes

No

 


 


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 Copyright 2017 R.P. Schifiliti Associates, Inc..
Last updated: 01/13/17.