Oae Hearing Screening Form
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1OAE Hearing Screening Form
Network ____________________
Child’s Name_________________________________________________
Child Information
__________________________
Date of Birth: (____/____/____)
Child’s ID #
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Indicate whether Initial Screen, Periodic Rescreen,
Male
Female
or Follow-up Rescreen, and provide corresponding information:
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– Screened for hearing loss at birth?
Unknown
Not screened
Passed
Referred
Initial Screen
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– Performed after referral for Medical or Audiological Follow-up
Follow-up Rescreen
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□
□
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–
Annual
Semi-annual
Other ____________________________________
Periodic Rescreen
Hearing
Screener:
Location:
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Screening
Name ___________________________
Home
Daycare setting
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Data
Center
Other __________
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Title _____________________________
Part C Program
Child’s LEFT Ear
Visual Inspection
Follow-up
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Rescreen
Refer — Date (___/___/___)
Medical
after medical
□
(___/___/___)
treatment &
Pass
Target date
record results
1st OAE
2nd OAE
on additional
Date (___/___/___)
(___/___/___)
Screening
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Form.
Can’t test
Can’t test
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Refer
Refer
If OAE Rescreen following medical
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If child has
treatment does not result in a Pass
Pass
Pass
□
a permanent
Audiological
Notes:
hearing loss,
(___/___/___)
refer to Early
Target date
Intervention.
Child’s RIGHT Ear
Visual Inspection
Follow-up
□
Rescreen
□
Refer — Date (___/___/___)
Medical
after medical
□
treatment &
(___/___/___)
Pass
record results
Target date
on additional
1st OAE
2nd OAE
Screening
Date (___/___/___)
(___/___/___)
Form.
□
□
Can’t test
Can’t test
□
□
If OAE Rescreen following medical
Refer
Refer
□
□
treatment does not result in a Pass
If child has
Pass
Pass
□
a permanent
Audiological
Notes:
hearing loss,
(___/___/___)
refer to Early
Target date
Intervention.
Time Data
Approximate total time with child required for screening (in minutes):
1st OAE ______
2nd OAE ______
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Parent category: Medical