HEARING AND VISION TEST RESULTS



HEARING TEST RESULTSHS1302.42 (1) Child Health Status and CarePolicy: 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 EnrollmentTests completed within 45 days of Enrollment YES NONotesSelect Testing Method UsedNEWBORN HEARING TEST (completed within 45 days of enrollment, using evidence based screener)Date Complete:PASSFollow up (if needed) OTOACOUSTICS SCREENING-RIGHT EAR296227559055Attach print out here00Attach print out hereRIGHT EARInitial ScreenDate:_______________Child UncooperativeCan’t Test ______________ReferPASS-do not need rescreenRIGHT EARRe-Screen298132515875Attach print out here00Attach print out hereDate:_______________Child UncooperativeCan’t Test ______________ReferPASS-does not need medical follow upRIGHT EARFollow UpMedical Target Date:________________HEARING TEST PAGE 2 Child’s Name:OTOACOUSTICS SCREENING-LEFT EAR298132519685Attach print out here00Attach print out here LEFT EARInitial ScreenDate:_______________Child UncooperativeCan’t Test ______________ReferPASS-do not need rescreenLEFT EARRe-Screen300037524130Attach print out here00Attach print out hereDate:_______________Child UncooperativeCan’t Test ______________ReferPASS-do not need medical follow upLEFT EARFollow UpMedical Target Date:________________If the screening results in a pass, this means the sound stimulus traveled from the probe to the inner ear and the inner ear responded by sending an optoacoustic emission back to the probe. Screening is complete for that ear.HS1302.42 (2) Child Health Status and CarePolicy: 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 PASS for any reason, including noise or lack of cooperation, further investigation is needed:SCREEN again (OAE 2) in two weeks in case the first result was due to screener error or a temporary condition (like a head cold).If the ear still does NOT PASS:REFER the child to a healthcare provider who can check whether a common problem, such as blockage in the outer ear or fluid in the middle ear is present. These conditions may block the sound stimulus from reaching the inner ear or the OAE response from returning to the probe. Medication or treatment may be necessary.RESCREEN (OAE 3) the ear after medical clearance. If you get another REFER:REFER the child to an audiologist who can evaluate whether a permanent hearing 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 have received the diagnostic results.VISION TEST RESULTSHS1302.42 (1) Child Health Status and CarePolicy: 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 EnrollmentTests completed within 45 days of Enrollment YES NONotesSURE SIGHT (completed within 45 days of enrollment)LEFT EYEInitial ScreenDate :PASSReferUncooperative/retestFollow Up Re-ScreenDate :PASSReferUncooperativeMedicalMedical Target Date:Result RIGHT EYEInitial ScreenDate:PASSReferUncooperative/retestFollow UpRe-ScreenDate:PASSReferUncooperativeMedicalMedical 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:NormalFollow up (if needed) Notes:HS1302.42 (2) Child Health Status and CarePolicy: 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, further investigation 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 or an evaluation has been completed by a healthcare professional, using an evidence based screener, and you have received 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 ASQ 3 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 or an evaluation has been completed by a healthcare professional and you have received the diagnostic results.References: HS1302.42 b.2. (1) HS1302.42 d.1.2. (2) 5/17 p:hs/ehs/health/H&V test results ................
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