HYDE PARK CENTRAL SCHOOL DISTRICT

P.O. Box 2033

Hyde Park,  New York 12538-8033

Date: _________________                                          School:  _______________________

PARENT NOTIFICATION REGARDING HEARING

           PART I                                

__________________________________________________________________________________________Pupil’s Name:                                                                                               Date of Birth:

__________________________________________________________________________________________

Address:                                                                                                         Grade:

__________________________________________________________________________________________

To Parent or Guardian:

            A recent threshold acuity test indicates that your child shows signs of hearing difficulty.  A complete otological examination is recommended to determine the need for professional care and to assist school personnel in making any necessary adjustment of the educational program.  This form should be completed by the examining physician and returned to the school nurse.

                                                                                                __________________________________________                                                                                                Signature of School Nurse

_________________________________________________________________________________________

To Physician:

            This pupil was found to have an average hearing loss of 20db or more as a result of a threshold acuity test.  The following signs of hearing difficulty have been observed by school personnel:  _________________

__________________________________________________________________________________________

Report of school’s threshold acuity test:

            500 1000 2000  3000  4000 6000                               500 1000 2000  3000  4000  6000

Right                                                                           Left                                                    

 

1.  Pupil working at grade level?                                 Yes                  No

2.  Previous specialized educational services provided:  _____________________________________________

__________________________________________________________________________________________

3.  Special educational services now provided:

 

     A.  Auditory training                     Yes                  No

 

     B.  Speech reading                          Yes                  No

 

     C.  Speech correction                     Yes                  No

     D.  Other special instructional services:  ______________________________________________________

    

     ______________________________________________________________________________________

PART II – AUDIOMETRIC AND MEDICAL FINDINGS

To the Private Health Care Provider:

            Any child who is found to have a significant hearing loss should have a speech discrimination test (P.B.Max) administered.  The test results assist school authorities in planning education services.

FREQUENCY IN HERTZ

Please record both air and bone threshold                      

0	500	1000	2000	4000	6000
10
20
30
40
50
60
70
80
90
100
110
120

                       

                        LEGEND

           

                 1969 ANST Standard

 

PB Score ___________% binaural                 With hearing aid(s)                                                                    

 

State level of presentation ________dB         Without aid (only if no aid advised)

1.         Diagnosis of hearing loss ___________________________________________________________

2.         Prognosis  _______________________________________________________________________

3.         Further medical procedures recommended  _____________________________________________

 

            ________________________________________________________________________________

           

4.         Is a hearing aid indicated ?      Yes             No                        Monaural             Binaural

5.         Remarks _________________________________________________________________________

6.         When should this child be seen again?  _________________________________________________

           

            ______________________________            Signature:   ___________________________________

                        Date of examination

                                                                                    Printed Name:  ________________________________

                                                                                                                        (Health Care Provider)

                                                                                    Address:   ____________________________________

Revised 2005