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