Vision And Hearing Screening Form
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SCHOOL BUILDING LEVEL COMMITTEE/REFERRAL
Vision and Hearing Screening
Student ’ s Name: ___________________________ SS Number: ________________ DOB: ____________ Medicaid: __N or __Y
_____Initial Referral
_____Re-Evaluation Referral
Date Referred to SBLC ___________________________
Sensory Screening - To Be Completed On All Referrals
(Optional On Referrals For Possibly Gifted Students)
Hearing:
_______Normal _______At Risk--Date Screened: ________/________/________
Screening Results
__Pass – Normal Peripheral Hearing for at least the better ear
Sound Field Screening (_____ - 4000Hz)
__At Risk
__Pass – Normal Peripheral Hearing for at least the better ear
Behavioral Observation Audiometry (____-4000Hz)
__At Risk
__Pass – Normal Peripheral Hearing for at least the better ear
Visual Reinforcement Audiometry (____-4000Hz)
__At Risk
__Pass – Normal Peripheral Hearing bilaterally
Pure-Tone Screening (____-4000Hz)
__At Risk
__Pass – Normal Middle Ear Function bilaterally
Immittance Screening:
__At Risk
__Pass – Normal Cochlear Function bilaterally
Otoacoustic Emissions Screening (1000-4000Hz)
__At Risk
Response during screening:
_______ Good ________ Unresponsive
Could not screen due to: ________________________________________________________________________________________
Comments: __________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_______________________________________ - School Nurse/Speech Therapist/Audiologist ____________________- Date
Vision:
_______Normal _______At Risk--Date Screened: ________/________/________
1.
Acuity
____ Normal ____ At Risk -- Acuity _______ Instrument Used__________________
2.
Color Blindness
____ Normal ____ At Risk -- Instrument Used_________________________________
3.
Muscle Balance
____ Normal ____ At Risk -- Instrument Used_________________________________
4.
Response during screening
____ Good
____ Unresponsive
Comments: ___________________________________________________________________________________________________
_____________________________________________________________________________________________________________
___________________________________________________________ - School Nurse _______________________ - Date
Additional Screening
: If there is a concern regarding communication skills (articulation, language, voice, or fluency)
screening in these areas should be conducted by the speech therapist (see SBLC Speech & Language Screening form).
Provide Copies To:
Special Education Office
School
Parent
Revised 8/2013 - form3a.vjm
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