Hearing And Vision Opt Out Form

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HEARING AND VISION OPT OUT FORM
ALA CAMPUS:____________________________________
SCHOOL YEAR: 20___/20___
STUDENT NAME: _________________________________
GRADE/TEACHER: ___________________
Dear Parents,
Hearing and vision screening will be conducted throughout the school year. Arizona Revised Statutes
36.899.01-.04 mandates all Arizona educational institutions provide hearing screening referrals to school age
children. The mandate requires that all private, charter, and public schools make available to its students a
systematic screening for hearing disorders in order to allow early identification of appropriate intervention. The
statute also states that the parent may refuse to have their child screened. If you desire for your student to opt
out of the hearing screening, please return this form to your campus health office; otherwise they will be
screened. The results of the screenings are gathered and a school administrator submits an annual mandated
state report to the Arizona Department of Health Services at the end of the school year.
The vision screen is not state mandated; however, the purpose of this program is to identify possible visual
problems as early as possible so that the need for intervention can be determined. Early detection and
intervention may prevent educational implications such as difficulty reading. If you desire for your student to
opt out of the vision screening, please return this form to your campus health office; otherwise they will
be screened.
Parents will be notified of their child’s results only if your child fails two screenings on two different dates.
Further consultation and follow up from your primary care physician, audiologist or optometrist is
recommended.
If you have any questions, please feel free to contact me at .
Thank you,
Marci Roberts, RN
ALA Health Program Coordinator
If you DO NOT want your student’s hearing or vision tested, please return this form to the school health office.
____ I DO NOT give permission for my child’s hearing to be tested at the school.
____ I DO NOT give permission for my child’s vision to be tested at the school.
Parent Signature:_______________________________
Date:____________________________
Corporate Office: 2350 E Germann Rd,Suite 24 Chandler, AZ 85286 wPhone:(480)420-2101 w Fax(480)987-4527
Rev 1/2016 F-2

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