HEARING SCREENING FORM

STUDENT’S NAME  						  SCHOOL YEAR  					

SCHOOL  								  GRADE  					

INITIAL EXAMINER: ____________________________________________  DATE: _____________________________________

HEARING CRITERIA:  Puretone Audiometry-Tympanometry.  A student fails the screening test if he/she does not respond to any one tone (frequency) at 20db hearing level in either ear.

KEY:  P = PASS     F = FAIL

Screening Date:  			
	
Recheck Date:  					

EAR	
HL	
FREQUENCY HZ
	
EAR	
HL	
FREQUENCY HZ

1000
	
2000	
4000			
1000	
2000	
4000	

RE
	
20				
RE	
20				

LE
	
20				
LE	
20				

Examiner:  							Examiner:  						
Audiometer:  							Audiometer:  						
Last Calibration Date:  						Last Calibration Date:  					

Tympanometry:	RE  						Tympanometry:	RE  			
		LE  									LE  			

REMARKS:								REMARKS:

[   ]  Within Normal Limits						[   ]  Within Normal Limits
[   ]  Needs Rescreen (within two weeks)					[   ]  Needs Rescreen (within two weeks)
[   ]  Needs Referral							[   ]  Needs Referral

Resolution of Problem:  														

																

If the child cannot be conditioned to pure-tone audiometry, an auditory response screener may be used.

Date:  		___		
[   ] Pass 		 [   ] Fail
Examiner:  								

Optional Form for Required Procedure/Evaluation.