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Ongoing research at Boys Town National Research Hospital seeks to maximize the benefits of a cochlear implant. Researchers and clinicians are studying optimal rehabilitative intervention strategies for infants and children.

Boys Town National Research Hospital
Bilateral Cochlear Implant Study
Online Pre-Enrollment Form

If you are interested in being contacted as a potential participant in our study, please fill out the form below.  We are looking for either adult bilateral CI users or parents/caregivers of children who use bilateral cochlear implants to participate in the study.  For our study, bilateral CI users must have received their implants in two separate surgeries, with a minimum of six months’ time between receipt of the first and second implants.
Once this form is submitted, your information will be sent to a member of our research staff.  The researcher will contact you and ask a series of questions regarding contact information and verification of inclusion criteria for this study.  Please note that filling out this form does not automatically enroll you in the study.  All information will be kept confidential and will not be shared with anyone.  If you do not qualify for the study, your information will be permanently removed from our records.


 
*Last Name:

Check one:           

Preferred day/time to call:

*

*Preferred method for us to contact you (check one):



*The person filling out this form is (check one):

Parent or guardian of a child under the age of 19 who has bilateral cochlear implants (please be sure that your name is listed above, not the child’s name)

Adult bilateral cochlear implant recipient, age 19 or older