School Hearing Screening Worksheet

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Child’s Name: ______________________________________________________

Teacher: __________________________________________________________

Grade: ____________________________ Date: _________________________

Parent/Teacher/Child Concerns about hearing:

Visual Inspection: With in Normal Limits (WNL) Rescreen
External    
Otoscopy    
Tympanometry Results: WNL RESCREEN

PURE TONE:

Screen: Head Cold Pass Rescreen
Level (dB) 25 20 20 20
Frequency (Hz) 500 1000 2000 4000
Right Ear        
Left Ear        
Rescreen: Head Cold Pass Rescreen
Level (dB) 25 20 20 20
Frequency (Hz) 500 1000 2000 4000
Right Ear        
Left Ear        
Threshold in HL: Head Cold Date ___ / ___ / ___
Frequency (Hz) 500 1000 2000 4000
Right Ear (dB) (dB) (dB) (dB)
Left Ear (dB) (dB) (dB) (dB)
Reliability: Good Fair Poor

Form Completion (Marking):

  black checkmark Hollow checkmark with a black line through it. hollow checkmarkblack checkmark
Response
(leave blank)		 No Response Response
on ImRe		 No Response
on ImRe
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