Appendix C: Answer Form for the MAPA 1.0 — Form A Name Date: DOB Age 500 1000 Sex 2000 Examiner 4000 OAE Pressure Volume Comp Right Left Note: Set audiometer to 50 dB HL or at patient’s MCL. Tape A = Right; Tape B = Left Monaural Separation Closure (MSC) mSAAT Non-competing (3) NC-R (4) NC-L (5) Please _____ Bad _____ Great _____ Such _____ Sled _____ Need _____ Pants _____ Five _____ Rat _____ Rag _____ Total _____ Total _____ mSAAT Competing Instructions (6) Instructions (8) C-R (7) C-L (9) School _____ Broom _____ Ball _____ Bowl _____ Smoke _____ Coat _____ Floor _____ Door _____ Fox _____ Socks _____ Hat _____ Flag _____ Pan _____ Fan _____ Bread _____ Red _____ Neck _____ Desk _____ Stair _____ Bear _____ Eye _____ Pie _____ Knee _____ Tea _____ Street _____ Meat _____ Wing _____ String _____ Mouse _____ Clown _____ Shirt_____ Church _____ Gun _____ Thumb _____ Bus _____ Rug _____ Train _____ Cake _____ Arm _____ Barn_____ Chick _____ Stick _____ Crib _____ Ship _____ Wheel _____ Seal _____ Straw _____ Dog _____ Pail _____ Nail _____ Total ____/25 Total ____/25 Auditory Pattern Temporal Ordering (APTO) Tap Test Instructions: (10) If they answer with anything but a number, prompt them with “think back and tell me how many you heard”. Practice (11) 1. _____(5 Taps) 2. _____(7 Taps) Test (12) Tap 1: _________ (8 Taps) Tap 2: _________ (12 Taps) Tap 3: _________ (10 Taps) Total for Tap 1,2,3 _____/30 Pitch Pattern Instructions: (13) Binaural (14) “You try…”__________ LHHH _________ HHLL _________ LHLL _________ HHLH _________ HHHL _________ LHHL _________ HLLL _________ LLLH _________ HLHH _________ LLHH _________ HLHL _________ LHLH _________ HLLH _________ LLHL _________ HHHL _________ LLLH _________ HLHH _________ HHLL _________ HHLH _________ LHHH _________ Total _________/20 Name: Binaural Integration Binaural Separation (BIBS) Dichotic Digits Right Ear 1st (16) 3 5 2 / 1 8 6 4 1 8 / 6 2 5 2 1 9 / 5 4 8 2 5 4 / 6 3 1 5 4 8 / 2 6 3 4 1 9 / 3 2 6 3 8 1 / 6 9 4 2 9 6 / 1 3 8 9 6 1 / 4 8 3 9 2 4 / 5 8 1 Instructions (15) Left Ear 1st (17) 2 5 3 / 8 6 9 8 4 9 / 5 2 6 9 1 2 / 8 4 5 3 5 2 / 1 4 6 8 1 5 / 3 9 2 9 1 4 / 6 5 3 1 9 4 / 6 3 2 5 6 2 / 8 3 9 9 4 6 / 1 2 8 4 2 9 / 6 8 5 Competing Sentences Instructions (18) Rt Ear First (19) - Circle L/R of correct sentences 1. R - The caboose is always last. L - This is a long freight train. 2. R - Recess is my favorite time. L - I don’t like to go to school either 3. R - Put gas in the tank. L - My car is very fast. 4. R - I do not like to eat dinner alone. L - They say candy is bad for your teeth 5. R - That scratch may get infected. L - Put a clean bandage on that cut. 6. R - I saw it when it was a play. L - That movie was on TV. 7. R - There are lions and tigers in the zoo. L - I saw lots of different kinds of animals. 8. R - Don’t forget your father’s birthday. L - My sister has a new boyfriend 9. R - I had to take a nap. L - He is only resting. 10. R - He’s off for Easter week. L - I had a wonderful Christmas. 11. R - Visit your grandmother on Sunday. L - Make sure you call your brother this week. 12. R - Summer is finally here. L - The sun is finally shining. 13. R - Did your boss give you a raise? L - Do you have to take many business trips? 14. R - Goldfish are easy to keep. L - That dog likes to run. 15. R - He doesn’t like his new boss. L - Make sure you get to work on time. Total ___/30: Note: Sentences must be exact to be scored correct. Right 1st Total _____/60 any order Left 1st Total______/60 any order R/L Total________/120 any order Competing Sentences Instructions (20) Lt Ear First (21) - Circle L/R of correct sentences. 1. L - It was a long ride by car. R - I thought we would never get there. 2. L - He went to the South on his vacation. R - I get two weeks off in the summer. 3. L - Make sure you deposit that check. R - I need to borrow five dollars. 4. L - I put the letter in the mailbox. R - You must write to her more often. 5. L - He drank all of the milk. R - I like my coffee black. 6. L - When did your dog get sick? R - Do you want to buy that cute puppy? 7. L - He was very late to class yesterday. R - I went to the cafeteria at noon. 8. L - The airplane flew very low. R - The jet took off smoothly. 9. L - I have the best teacher in school. R - He was a student here before me. 10. L - I saw the funny clown. R - The circus was very good. 11. L - What’s your address? R - They bought a new house. 12. L - I never saw a bear. R - Cats have whiskers. 13. L - How many of your brothers live at home? R - How long have your parents been married? 14. L - She has a fever. R - See your doctor. 15. L - How much snow fell? R - Has it started raining? Total ___/30: Note: Sentences must be exact to be scored correct. Name: Supplementary Tests Duration Patterns Binaural Instructions (22) Test (23) “You try…” ______ LSSS _____ SSLL _____ LSLL _____ SSLS _____ SSSL _____ LSSL _____ SLLL _____ LLLS _____ SLSS _____ LLSS _____ SLSL _____ LSLS _____ SLSS _____ LLSL _____ SSSL _____ LLLS _____ SLLS _____ SSLL _____ SSLS _____ LSSS_____ Total _____/20 Comments: SINCA Instructions (24) Right (25) +20 dish teach pinch pink *(___) +16 bead bath tree shop _____ +12 five rat mouth box _____ +8 fed such need hunt _____ +4 ride class hit scab _____ +0 great smile pond sled _____ Total number correct (*exclude +20) ____/20 Score: 18 - Total # correct = ____SNR SINCA Instructions (26) Left (27) +20 hot please few cart *(___) +16 bad pants slip law _____ +12 ways thank fold bus _____ +8 slice rag put did _____ +4 take beef neck suit _____ +0 turn darn laugh clamp _____ Total number correct (*exclude +20) ____/20 Score: 18 - Total # correct = ____SNR AFT-R (Gap Detection Test) Instructions (28) Test items: (29) Practice 1 ______ Practice 2 ______ 5 _____ 10 _____ 40 _____ 15 _____ 20 _____ 2 _____ 30 _____ 0 _____ 25 _____ Lowest msec gap detected (i.e. lowest number w/2 ______ Appendix C: Answer Form for the MAPA 1.0 — Form B Name Date: DOB Age 500 1000 Sex 2000 4000 Examiner OAE Pressure Volume Comp Right Left Note: Set audiometer to 50 dB HL or at Patient’s MCL. Tape A = Right; Tape B = Left Monaural Separation Closure (MSC) mSAAT Non-competing (31) NC-R (32) NC-L (33) Please _____ Bad _____ Great _____ Such _____ Sled _____ Need _____ Pants _____ Five _____ Rat _____ Rag _____ Total _____ Total _____ mSAAT Competing Instructions (34) Instructions (36) C-R (35) C-L (37) Moon _____ Spoon _____ Bell _____ Bow _____ Coke _____ Goat_____ Corn _____ Horn _____ Box _____ Blocks _____ Bag _____ Black _____ Can _____ Man _____ Thread _____ Bed _____ Nest _____ Dress _____ Chair _____ Pear _____ Fly _____ Tie _____ Key _____ Bee _____ Feet _____ Teeth _____ Spring _____ Ring _____ Crown _____ Mouth _____ Dirt _____ Church _____ Sun _____ Gum _____ Cup _____ Bug _____ Snake _____ Plane _____ Car _____ Star _____ Dish _____ Fish _____ Bib _____ Lip _____ Queen _____ Green _____ Saw _____ Frog _____ Jail _____ Tail _____ Total ____/25 Total ____/25 Auditory Pattern Temporal Ordering (APTO) Tap Test Instructions: (38) If they answer with anything but a number, prompt them with “think back and tell me how many you heard”. Practice (39) 1. _____(5 Taps) 2. _____(7 Taps) Test (40) Tap 1: _________ (8 Taps) Tap 2: _________ (12 Taps) Tap 3: _________ (10 Taps) Total for Tap 1,2,3 _____/30 Pitch Pattern Instructions: (41) Binaural (42) “You try…”__________ LLHH _________ LHLH _________ LLHL _________ HHLH _________ HLLL _________ HLHH _________ LHHH _________ LLLH _________ HLLH _________ HHHL _________ HHLL _________ LHHL _________ HLHL _________ LHLL _________ HLLH _________ HLHL _________ HHLL _________ HHHL _________ LHHL _________ LHHH _________ Total _________/20 Name: Binaural Integration Binaural Separation (BIBS) Dichotic Digits Instructions (43) Right Ear 1st (44) 6 8 1 / 2 5 3 5 2 6 / 8 1 4 8 4 5 / 9 1 2 1 3 6 / 4 5 2 3 6 2 / 8 4 5 6 2 3 / 9 1 4 4 9 6 / 1 8 3 8 3 1 / 6 9 2 3 8 4 / 1 6 9 1 8 5 / 4 2 9 Left Ear 1st (45) 9 6 8 / 3 5 2 6 1 5 / 9 4 8 5 4 8 / 2 1 9 6 4 1 / 2 5 3 2 9 3 / 5 1 8 3 5 6 / 4 1 9 2 3 6 / 5 1 8 9 3 8 / 2 6 5 8 2 1 / 6 4 9 5 8 6 / 9 2 4 Competing Sentences Instructions (46) Rt Ear First (47) - Circle L/R of correct sentences 1. R – The children played tag for a long time. L – I think hide and seek is a lot of fun. 2. R – I was able to go to the park. L – They went to the zoo Sunday. 3. R – Your uncle is not over there. L – My sister is older than I am. 4. R –I think I hear a radio playing. L – There’s a color television over there. 5. R – I like to run my model train. L – He’s too old to play with toys. 6. R – I had a sandwich for lunch. L –There was fried chicken for dinner. 7. R – I put strawberries on my ice cream. L – Dessert was a chocolate sundae. 8. R – I like maple syrup on my waffles. L – Mother made pancakes for breakfast. 9. R – They won’t answer the phone. L – Nobody is at home. 10. R – There’s a lot of snow on the ground. L – It’s raining very hard. 11. R – We’re going to paint the guest bedroom next week. L – She just moved into a 3 room apartment. 12. R – She’s the one who gives singing lessons. L – The free concerts are wonderful. 13. R – She wants to start buying some stock. L – Do you think we should buy him a savings bond? 14. R – How much is the bill? L – Can I pay by check? 15. R – Practice the guitar. L – Turn the radio off. Total ___/30: Note: Sentences must be exact to be scored correct. Right 1st Total ______/60 any order Left 1st Total _______/60 any order R/L Total_________/120 any order Competing Sentences Instructions (48) Lt Ear First (49) - Circle L/R of correct sentences. 1. L – Do you want gravy on your potatoes? R – Do you want to have a BBQ this evening? 2. L – Visit your grandmother on Sunday R –How long have your parents been married? 3. L – Will you go to the beach even if it’s still cloudy? R – Will you be going on vacation in the spring? 4. L – Did you remember to call you grandmother? R – Does he still live with his parents? 5. L – Do you know of a good band for the party? R – She’s the one who gives singing lessons. 6. L – How much did they charge you for the alterations? R – Buy that bathing suit because it fits you. 7. L – Pass the bread and butter. R – Cake is sweet. 8. L – How many cats do you have? R - Don’t let the dog off his leash. 9. L – Don’t try to run unless you have good shoes. R – Bring your sneakers to the exercise class. 10. L – Wear a heavy sweater since it’s cold. R – Take the dog out before it snows. 11. L – Have you eaten yet? R – I want coffee. 12. L – Play that song. R – Can you sing? 13. L – Bring your sneakers to the exercise class. R – I don’t like to swim in an indoor pool. 14. L – Can she ice skate? R – Throw me the ball. 15. L – Please turn on the coffee. R – What do you want for lunch? Total ___/30: Note: Sentences must be exact to be scored correct. Name: Supplementary Tests Duration Patterns – Binaural Instructions (50) Test (51) “You try…”______ LLSS _____ LSLS _____ LLSL _____ SSLS _____ SLLL _____ SLSS _____ LSSS _____ LLLS _____ SLLS _____ SSSL _____ SSLL _____ LSSL _____ SLSL _____ LSLL _____ SLLS _____ LSLS _____ SSLL _____ SSSL _____ LSSL _____ LSSS_____ Total _______/20 Comments: SINCA Instructions (52) Right (53) +20 tire seed room bug *(___) +16 that sell rich those _____ +12 black nest had cost _____ +8 fit bounce wide most _____ +4 thick them dad ship _____ +0 case choose white frog _____ Total number correct (*exclude +20) ____/20 Score: 18 - Total # correct = ____SNR SINCA Instructions (54) Left (55) +20 bush +16 pass +12 leave +8 paste +4 park +0 knife clown grade nuts page wait turn cab blind laugh weed fat grab hurt drop falls gray cage rose *(___) _____ _____ _____ _____ _____ Total number correct (*exclude +20) ____/20 Score: 18 - Total # correct = _____SNR AFT-R (Gap Detection Test) Instructions (56) Test items: (57) Practice ______ Practice ______ 5 _____ 10 _____ 40 _____ 15 _____ 20 _____ 2 _____ 30 _____ 0 _____ 25 _____ Lowest msec gap detected (i.e. lowest number w/2 ______ MAPA SUMMARY SHEET MAPA Summary Name_____________________Age____ Domain MSC APTO BIBS Test MSAAT RE MSAAT LE Tap Test Pitch Pattern DD CS Rt Ear CS Lt Ear Raw Score If age 11, use mean data based on closest grade. -1 SD based on age * * * * * * * -2 SD based on age ** ** ** ** ** ** ** Circle 2 stars for - 2 SD or 1 star for - 1 SD if raw score is lower than mean data from Appendix B which you fill in above. Severity Domain MSC APTO BIBS Total Domains ________ Total Stars ________ (0-3) (-2 SD only) (only count stars if there is at least one domain at -2 SD) Supplementary Tests Test Raw -1 SD Score based on age SINCA RE * SINCA LE * # _______ * DP * AFT-R (Gap * Detection Test) ## _______ * ###_______ * ###_______ * # SCAN AFG or SCAN FW, QUICKSIN, BKB-SIN, etc. ## GIN, AFT-R, etc ### SCAN CW, SCAN CS, etc -2 SD based on age ** ** ** ** ** ** ** **