Hearing and Vision Test Results
HEARINGTEST RESULTS
HS1302.42 (1) Child Health Status and Care
Policy: Within 45 calendar days after the child first attends the program or, for the home-based program option, receives a
home visit, a program must either obtain or perform evidence-based vision and hearing screenings.
Procedure:
Child’s Name ______Birthdate
Enrollment Date______Age at Enrollment
Tests completed within 45 days of Enrollment YES NO
Notes
Select Testing Method Used
NEWBORN HEARING TEST(completed within 45 days of enrollment, using evidence based
screener)
Date Complete:
PASS
Follow up (if needed)
OTOACOUSTICS SCREENING-RIGHT EAR
RIGHT EAR
Initial Screen
Date:______
Child Uncooperative
Can’t Test ______
Refer
PASS-do not need rescreen
RIGHT EAR
Re-Screen
Date:______
Child Uncooperative
Can’t Test ______
Refer
PASS-does not need medical
follow up
RIGHT EAR
Follow Up
Medical
Target Date:______
HEARING TEST PAGE 2
Child’s Name:
OTOACOUSTICS SCREENING-LEFT EAR
LEFT EAR
Initial Screen
Date:______
Child Uncooperative
Can’t Test ______
Refer
PASS-do not need rescreen
LEFT EAR
Re-Screen
Date:______
Child Uncooperative
Can’t Test ______
Refer
PASS-do not need medical
follow up
LEFT EAR
Follow Up
Medical
Target Date:______
If the screening results in a pass, this means the sound stimulus traveled fromthe probe to the inner ear and the innerear responded by sending an optoacoustic emission back to the probe.Screening is complete for that ear.
HS1302.42 (2) Child Health Status and Care
Policy: A program must facilitate further diagnostic testing, evaluation, treatment, and follow-up plan, as appropriate, by a licensed or certified professional for each child with abnormal hearing or vision results that may affect child’s development, learning, or behavior. A program must develop a system to track referrals and services provided and monitor the implementation of a follow-up plan to meet any treatment needs associated with a health problem.
Procedure:
If a rescreen is needed, enter the date the screening was attempted, along with the date of the rescreen into Child Plus. Referrals will be sent to providers using the Head Start Referral Form along with the Disclosure with Parental Consent form and tracked in Child Plus.
If an ear does NOT PASSfor any reason, including noise or lack of cooperation, furtherinvestigation is needed:
- SCREEN again (OAE 2) in two weeks incase the first result was due to screenererror or a temporary condition (like a headcold).
If the ear still does NOT PASS:
- REFER the child to a healthcare provider who can check whether a commonproblem, such as blockage in the outer earor fluid in the middle ear ispresent. These conditions may block thesound stimulus from reaching the inner earor the OAE response from returning to theprobe. Medication or treatment may benecessary.
RESCREEN (OAE 3) the ear after medical clearance.If you get another REFER:
- REFER the child to an audiologistwho can evaluate whether a permanenthearing loss is present. This referral may need to be made by the child’s healthcare provider, depending on the child’s insurance.
The hearing screening and follow-up process is COMPLETE ONLY when:
Both ears PASS the OAE Screening, or An AUDIOLOGICAL EVALUATION has been completed and you havereceived the diagnostic results.
VISION TEST RESULTS
HS1302.42 (1) Child Health Status and Care
Policy: Within 45 calendar days after the child first attends the program or, for the home-based program option, receives a
home visit, a program must either obtain or perform evidence-based vision and hearing screenings.
Procedure:
Childs Name ______Birthdate
Enrollment Date______Age at Enrollment
Tests completed within 45 days of Enrollment YES NO
Notes
SURE SIGHT (completed within 45 days of enrollment)
LEFT EYE
Initial Screen
Date :
PASS
Refer
Uncooperative/retest
Follow Up
Re-Screen
Date :
PASS
Refer
Uncooperative
Medical
Medical Target Date:
Result
RIGHT EYE
Initial Screen
Date:
PASS
Refer
Uncooperative/retest
Follow Up
Re-Screen
Date:
PASS
Refer
Uncooperative
Medical
Medical Target Date:
Result
VISION TEST PAGE 2
Child’s Name:
ASQ(if child is 6mos or younger and completed within 45 days of enrollment)
Date:
Normal
Follow up (if needed)
Notes:
HS1302.42 (2) Child Health Status and Care
Policy: A program must facilitate further diagnostic testing, evaluation, treatment, and follow-up plan, as appropriate, by a licensed or certified professional for each child with abnormal hearing or vision results that may affect child’s development, learning, or behavior. A program must develop a system to track referrals and services provided and monitor the implementation of a follow-up plan to meet any treatment needs associated with a health problem.
Procedure:
If a rescreen is needed, enter the date the screening was attempted, along with the date of the rescreen into Child Plus. Referrals will be sent to providers using the Head Start Referral Form along with the Disclosure with Parental Consent form and tracked in Child Plus.
For children 6 months of age and older:
If an eye does NOT PASS for any reason, including lighting or lack of cooperation, furtherinvestigation is needed:
- If the vision screening results are outside of the typical range, refer the child to their healthcare provider or eye care professional.
- If a child was uncooperative, or if lighting was an issue, complete the screening again within two weeks.
- If the child is uncooperative at the time of the second screening, or if lighting continues to be an issue, refer the child to their healthcare provider or eye care professional.
For a child 6 months of age and older, the vision screening and follow-up process is COMPLETE ONLY when:
Both eyes pass the vision screening using an evidence based screener oran evaluation has been completed by a healthcare professional, using an evidence based screener, and you havereceived the diagnostic results.
For children under 6 months of age:
- If a child is under 6 months old, his or her vision has not developed fully and cannot be tested using our Sure Sight Equipment.
- For children enrolled before 6 months and who cannot be screened with the 45 day window because of their age, we will use information gathered on vision as a part of the ASQ3 screener we administer within this same 45 day window.
- In the section that asks for parent/provider comments, there is a question related to concerns about the child’s vision. You can use this parent/provider self-report section to meet the vision screening requirement for children under six months.
- In Child Plus, enter the date that the ASQ 3 screener was completed and whether or not there are any concerns expressed in this section by the parent/provider about the child’s vision.
- If concerns are expressed, refer the child to their healthcare provider or eye care professional.
For a child under 6 months of age, the vision screening and follow-up process is COMPLETE ONLY when:
No concerns are noted using the ASQ 3 screener oran evaluation has been completed by a healthcare professional and you havereceived the diagnostic results.
References: HS1302.42 b.2. (1) HS1302.42 d.1.2. (2)
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