SPEECH Or HEARING SCREENING

SPEECH or HEARING SCREENING

Site/School:______Child’s Name:______Age:______

This box is for the screener only:
Are there other concerns? ☐ Social Skills ☐ Developmental Delay Please use comment section

☐This child has an IEP/IFSP (DO NOT SCREEN) ☐ This child is absent:______

P=Pass R=Refer B=Borderline/Rescreen CNC=Could Not Condition CNT=Could not test (must note why)

Hearing (1st Attempt) / Hearing (2nd Attempt)
Examiner: / Date: / Examiner: / Date
Audiometer: / Intensity: / Audiometer: / Intensity:
Tymp #: / OAE #: / Tymp #: / OAE #:
1K / 2K / 4K / OAE / TYMP / Comment / 1K / 2K / 4K / OAE / TYMP / Comment
Right Ear: / Right Ear:
Left Ear: / Left Ear:
Recommendation(s): place mark on left side of choice below / Recommendation(s):place mark on left side of choice below
Audiologist Referral / Audiologist / Audiologist Referral / Audiologist
Medical Referral / Rescreen / Medical Referral – infection? / Rescreen
Rescreen after Doctor visit / Rescreen after Doctor visit

Screener/Audiologist’s Comments:______

______

P=Pass R=Refer B=Borderline/Rescreen CNT=Could not test (must note why)

Speech (1st Attempt) / Speech (2nd Attempt)
Examiner: / Date: / Examiner: / Date:
Primary Language: __Engl ___SP ___Other ______/ Primary Language: __Engl ___SP ___Other_____
Language Screened: __Engl ___SP ___Other ______/ Language Screened:___Engl ___SP ___Other ____
Rating / Comment / Rating / Comment
Articulation / Articulation
Language / Language
Stuttering / Stuttering
Voice / Voice
Recommendation(s): place mark on left side of choice below / Recommendation(s): place mark on left side of choice below
None / Rescreen w/ interpreter / None / Rescreen w/ interpreter
Rescreen / Referral to LEA / Rescreen / Referral to LEA
SLP comments:

This page goes to the parent

*Parent, feel free to take this paper to your child’s doctor.

RESULTS FROM 1ST ATTEMPT Date: ______

□ Passed hearing screening / □ Passed speech/language/fluency/voice screening
□ Child would not participate in hearing screening / □ Child would not participate in speech/language screening
□ Hearing needs to be rescreened / □ Speech/language needs to be rescreened
□ Hearing: Your child has trouble hearing some sounds and needs to be tested by an audiologist
□Hearing: Your child needs to see a physician
□ possible middle ear problem
□ removal of wax
Left ear Right ear / Your child needs to be referred to the Local Education Agency for full evaluation for:
☐Articulation: how your child says certain sounds
☐Language: how your child uses or understands language
☐Fluency: how your child speaks with/without repetitions of sounds or words
☐Voice: quality of your child’s voice
☐Connection speech: how your child is understood by non-family members

RESULTS FROM 2ND ATTEMPT (if required)Date: ______

□ Passed hearing screening / □ Passed speech/language/fluency/voice screening
□ Child would not participate in hearing screening / □ Child would not participate in speech/language
screening
□ Hearing needs to be rescreened / □ Speech/language needs to be rescreened
□Hearing: Your child has trouble hearing some sounds and needs to be tested by an audiologist
□ *Hearing: Your child needs to see a physician
□ possible middle ear problem
□ removal of wax
 / Your child needs to be referred to the Local Education Agency for full evaluation for:
□ Articulation: how your child says certain sounds
□ Language: how your child uses or understands language
□ Fluency: how your child speaks with/without repetitions of sounds or words
□ Voice: quality of your child’s voice
□Connection speech: how your child is understood by non-family members

Left ear Right ear

Comments:

Family Service Worker______Phone:______

Email: ______

Revised 7/16