Appling County Vision And Hearing Screening Form
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1APPLING COUNTY VISION AND HEARING SCREENING FORM
Referred by the following:
______ RtI Committee/Contact Referral
THIS FORM MUST BE RETURNED VIA EMAIL by the school nurse.
After V&H consent is signed by parent, email this form to the school
______ SPED Referral
_______ Teacher Request
nurse who completes this vision & hearing form, DATES, saves to their
documents AND emails the results to the following individual:
______ 504 Referral
_______ Gifted Referral
Signed V& H Consent:
Contact Name: _____________________________________
______ Other: _____________________________
Contact person completes top portion before sending to nurse. When
the school nurse returns this completed form, the contact person will SAVE, download into GoIEP and/or place copy in file.
STUDENT
NAME:
___________________________________
GRADE: ______ SCHOOL: ___________________________
FIRST SCREENING: DATE _____________________________ HEARING
_________PASS
_________ FAIL
dB
dB
dB
dB
Rt. EAR
1000hz
2000hz
4000hz
500hz
Tympanogram
Lt. EAR
1000hz
2000hz
4000hz
500hz
Tympanogram
Passing frequencies at 25dB.
Note if method other than audiometer. _____ SCREENER NAME/Sig: _________________________________________
Sent notice of any failure for professional exam to parent on: ________________________________________________
SECOND SCREENING: DATE ___________________________ HEARING
_________PASS
_________ FAIL
dB
dB
dB
dB
Rt. EAR
1000hz
2000hz
4000hz
500hz
Tympanogram
Lt. EAR
1000hz
2000hz
4000hz
500hz
Tympanogram
Passing frequencies at 25dB.
Note if method other than audiometer. _____ SCREENER NAME/Sig: _________________________________________
FIRST SCREENING: DATE _____________________________ VISION
_________PASS
_________ FAIL
WEARS GLASSES? _______YES _______ NO
TESTED WITH GLASSES? _______YES _______ NO
UNCORRECTED
CORRECTED
Acuity Far
Plus Lens
Near Vision
Acuity Far
Plus Lens
Near Vision
Right
20/
20/
Right
20/
20/
Left
20/
20/
Left
20/
20/
20/
20/
Both
20/
20/
Both
Muscle
Muscle
Balance
Balance
Binocular
Binocular
Note if method other than Titmus. ______ SCREENER NAME/Sig: _____________________________________________
Sent notice of any failure for professional exam to parent on: ________________________________________________
SECOND SCREENING: DATE ___________________________ VISION
_________PASS
_________ FAIL
WEARS GLASSES? _______YES _______ NO
TESTED WITH GLASSES? _______YES _______ NO
UNCORRECTED
CORRECTED
Acuity Far
Plus Lens
Near Vision
Acuity Far
Plus Lens
Near Vision
Right
20/
20/
Right
20/
20/
Left
20/
20/
Left
20/
20/
Both
20/
20/
Both
20/
20/
Muscle
Muscle
Balance
Balance
Binocular
Binocular
Note if method other than Titmus. ______ SCREENER NAME/Sig: _____________________________________________
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