Hearing Screening Training Manual - Minnesota Department of Health

More documents

Recommendations

Info

EARLY CHILDHOOD HEARING SCREENING WORKSHEET (Also used for Child and Teen Checkups) SCREEN RESCREEN Name Age | Dates | | | | Yrs Mos Problem Noted: NO YES NO YES A. Risk Factors (29 days to 2 years) . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . B. Hearing History (all ages) . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . C. Auditory Checklist (birth to 24 mos.) . . . . . . . . . . . . . . . .. . . . . . . . . . . . . D. Visual Inspection/Otoscopy (all ages) . . . . . . . . . . . . . . . .. . . . . . . . . . . . E. Tympanometry (6 mos. +) If problems noted attach tympanogram. . . . . . F. Pure tone (3 years +). . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . Pure Tone: Screen: □ Head cold □ Pass □ Rescreen Level (dB) 25 20 20 20 Frequency (Hz) 500 1000 2000 4000 Right Ear Left Ear Rescreen: □ Head cold □ Pass □ Rescreen □ Refer Level (dB) 25 20 20 20 Frequency (Hz) 500 1000 2000 4000 Right Ear Left Ear Threshold in HL: □ Head cold Date _____/_____/_____ Frequency (Hz) 500 Right Ear 1000 2000 4000 8000 (dB) Left Ear (dB) (dB) (dB) (dB) (dB) (dB) (dB) (dB) (dB) Reliability: □ Good □ Fair □ Poor Hearing History (all ages): 1. Is there concern that this child has a hearing, speech or language problem? 2. Are there any childhood hearing problems in the family of either the child's mother or father? 3. Does child have history of middle ear disease and/or tubes? 4. Has child had head trauma with concussion, skull fracture or loss of consciousness? 5. Has child been hospitalized with a serious illness (i.e. kidney, meningitis) or diagnosed with amblyopia? 26
27 School Hearing Screening Worksheet Child’s Name______________________________________________________ Teacher______________________________ Grade_____ Date_____________ Parent/Teacher/Child Concerns about hearing: Visual Inspection: External Otoscopy Tympanometry Results Pass � RESCREEN � Pass Rescreen Pure Tone: Screen: � Head cold � Pass � Rescreen Level (dB) 25 20 20 20 Frequency (Hz) 500 1000 2000 4000 Right Ear Left Ear Rescreen: � Head cold � Pass � Rescreen Level 25 20 20 20 Frequency 500 1000 2000 4000 Right Ear Left Ear Threshold in HL: � Head cold Date__________________ Frequency 500 1000 2000 4000 8000 Right Ear Left Ear Reliability: � Good � Fair � Poor Form Completion (Marking): ✔ ✔ ✔ ✔ Response No Response Response No Response (leave blank) on ImRe on ImRe School Hearing Screening Worksheet Child’s Name______________________________________________________ Teacher______________________________ Grade_____Date______________ Parent/Teacher/Child Concerns about hearing: Visual Inspection: External Otoscopy Tympanometry Results Pass � RESCREEN � Pass Rescreen Pure Tone: Screen: � Head cold � Pass � Rescreen Level (dB) 25 20 20 20 Frequency (Hz) 500 1000 2000 4000 Right Ear Left Ear Rescreen: � Head cold � Pass � Rescreen Level 25 20 20 20 Frequency 500 1000 2000 4000 Right Ear Left Ear Threshold in HL: � Head cold Date__________________ Frequency 500 1000 2000 4000 8000 Right Ear Left Ear Reliability: � Good � Fair � Poor Form Completion (Marking): ✔ ✔ ✔ ✔ Response No Response Response No Response (leave blank) on ImRe on ImRe
Page 1 and 2: Hearing Screening Training Manual H
Page 3: TABLE OF CONTENTS BACKGROUND AND OV
Page 6 and 7: Unidentified hearing impairments in
Page 8 and 9: MINNESOTA DEPARTMENT OF HEALTH HEAR
Page 10 and 11: In addition, the provider will perf
Page 12 and 13: Ages/Grades: Infant through 36 mont
Page 14 and 15: JOINT COMMISSION ON INFANT HEARING
Page 16 and 17: the auditory system develops. Many
Page 18 and 19: Note: The 2007 JCIH Position Statem
Page 20 and 21: FREQUENCY OF SCREENING In the schoo
Page 22 and 23: Ages/Grades: All ages PARENT/TEACHE
Page 24 and 25: PURE TONE SCREENING Ages/Grades: Ag
Page 26 and 27: PURE TONE THRESHOLD SCREENING (OPTI
Page 32 and 33: HEARING REFERRAL LETTER Name_______
Page 34 and 35: THE AUDIOMETER An audiometer is a d
Page 36 and 37: ENVIRONMENTAL NOISE LEVEL CHECK Mos
Page 38 and 39: 34 DATE Power On Jacks Seated Earph
Page 40 and 41: Audiometer I.D._______________ Date
Page 42 and 43: Resources for Hearing Screening 38
Page 44 and 45: Screening site general consideratio
Page 46: NOISE INDUCED HEARING LOSS (NIHL) W
Page 49 and 50: HEARING RESOURCES ON THE WEB Hearin
Page 51 and 52: Biologic Check - Doing an audiogram
Page 53 and 54: Outer Ear - The part of the ear fro

Hearing Screening Training Manual - Minnesota Department of Health

Create successful ePaper yourself

Delete template?

Save as template?