Form Hea 0177 - Otoacoustic Emission (Oae) Hearing Screening Referral Report

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Otoacoustic Emission (OAE) Hearing Screening Referral Report
Date: __________________
To the Parent/Caregiver of ___________________________________________ D.O.B_________
School____________________________________________________ Grade_________
Your child is being referred for further evaluation because he/she failed our hearing screening procedure in our school. We are
using a hearing screening called “Otoacoustic Emissions (OAE). ” This is an objective test that records a physiological response from
the inner ear. Hearing problems can place your child at risk for learning difficulties. It is recommended that you take your child
to his/her primary care provider or audiologist for further evaluation. If you have any questions concerning the screening results,
please contact the school nurse. Please let the school nurse know if your child is already under a doctor’s care for hearing prob-
lems or if you need assistance in finding a medical provider. Please return the completed form to the school.
Otoacoustic Emission (OAE) Testing Results
Otoacoustic
Pass
Refer
Comments
Emissions (OAE)
Right Ear
Left Ear
“Pass” OAE means that the child has normal outer hair cell function; however, it does not rule out a mild hearing loss. OAEs do not
assess hearing acuity. A child’s peripheral hearing system has to be normal or within a normal range to pass this hearing proce-
dure. A child with a mild hearing loss up to 30-35dB can pass this screening.
“Refer” OAE can mean that the 1) the child has a potential hearing loss or, 2) the child may have middle ear problems that affects
the ability to record a response from the inner ear.
EVALUATION RESULTS (to be completed by the healthcare provider):
Diagnosis: _______________________________________________________________
Treatment Plan: ____________________________________________________________
Comments: ________________________________________________________________
Signature: ______________________________________Date of Examination: __________
Please return form to:_____________________________________
CONSENT AND RELEASE OF INFORMATION
I, __________________ (parent/caregiver) of the above named child, hereby authorize the provider completing this report to
return this completed form to:
_______________________________________________________
_______________________________________________________
_______________________________________________________
for the specific purpose of notifying the school of any specific hearing problems, recommendations and instructions for teachers re-
lated to the child’s hearing problems. This authorization expires upon submission of the completed form to the above named school.
I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment
for services or eligibility for benefits for my child; however, if this form is not submitted to the school, I understand that the school
may not have sufficient information to address special hearing needs for my child.
_______________________________________________________
__________________
(Signature of parent/caregiver)
(Date)
HEA 0177 (9/2015)

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