Audiology Referral
If you would like to have your student considered for USDB audiology services, please complete the form below.
NOTE: Parents must be informed of this referral
Notes (USDB personnel only)
Your answer
Parent Information
Parent Name *
Your answer
Parent Phone Number
Your answer
Parent Address *
Your answer
Parent City *
Your answer
Parent Zip *
Your answer
Parent State *
Parent Email Address
Your answer
Student Information
Student Name *
Your answer
Student Birthdate *
MM
/
DD
/
YYYY
Student Gender *
Student is Enrolled in: *
Name of School or EI Center *
Your answer
District where school is located *
Date of First Screening *
MM
/
DD
/
YYYY
Left Ear First Screening *
If N/A is selected, please select today's date above
Right Ear First Screening *
If N/A is selected, please select today's date above
Date of Second Screening *
MM
/
DD
/
YYYY
Left Ear Second Screening *
If N/A is selected, please select today's date above
Right Ear Second Screening *
If N/A is selected, please select today's date above
Does the child have one of the following diagnosis? Check all that apply
Already diagnosed with a hearing loss by a professional *
Required
Name of Person Referring
Referers Name *
Your answer
Title *
Your answer
Referrer Email Address *
Your answer
Referrer Phone Number *
Your answer
Additional Comments
Your answer
Referral Policy for USDB Audiological Services
Referral Policy for USDB Audiological Services
According to Utah Code Annotated 53A-25b-301, USDB can provide services to a resident of Utah that is 22 years of age or younger; referred to the Utah Schools for the Deaf and Blind by the person’s school district of residence or a local early intervention program; and identified as deaf, blind, or deafblind through a special education eligibility determination process or Section 504 eligibility determination process.
For assistance with a student whose hearing loss is in question, USDB will accept referrals for audiological services from a speech language pathologist, audiologists, nurse, early intervention specialist or special education director who has completed a hearing screening(s) at an early intervention center or school district of residence.   
REQUIRED INFORMATION:
The child needs to have two documented failed hearing screenings using an audiometer, Otoacoustic Emission (OAE), or Auditory Brainstem Response (ABR), in addition to delays in communication. Exceptions may be granted for a child who is uncooperative for routine screening procedures or has inconsistent test results from an OAE, ABR or booth evaluation.  
• The screener needs to include the dates of screenings or two attempts to screen.  The results for each ear need to be included with the referral.**
 Or the students with the following diagnosis’ do not require two failed hearing screenings:  
• ANSD - Auditory Neuropathy Spectrum Disorder

• Atresia/microtia

• A known syndrome with associated hearing loss such as Pierre Robin, CHARGE, Waardenburg, or other craniofacial abnormalities, etc.

ADDITIONAL INFORMATION (if available):
• A history of any known hearing loss, syndrome, or chronic middle ear condition (Defined as at least three documented ear infections or episodes of middle ear fluid within a three to six month period) that could cause a long-term hearing loss. Copies of previous hearing evaluations, or documentation of three or more ear infections within a six month period.

• Documentation of any medical condition that could cause a long-term educational hearing loss.  These medical conditions could include the following high risk factors: 

▪ Caregiver concern  regarding hearing, speech, language, or developmental delay.

▪ Family history of permanent childhood hearing loss.

▪ Neonatal intensive care of more than 5 days or any of the following regardless of length of stay: ECMO, assisted ventilation, exposure to ototoxic medications (gentimycin and tobramycin) or loop diuretics (furosemide/Lasix), and hyperbilirubinemia that requires exchange transfusion.

▪ In utero infections, such as CMV,herpes, rubella, syphilis, and toxoplasmosis.

▪ Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear pits, and temporal bone anomalies.

▪ Physical findings, such as white forelock, that are associated with a syndrome known to include a sensorineural or permanent conductive hearing loss.

▪ Syndromes associated with hearing loss or progressive or late-onset hearing loss such as neurofibromatosis, osteopetrosis, and Usher syndrome; other frequently identified syndromes include Waardenburg, Alport, Pendred, and Jervell and Lange-Nielson. 

▪ Neurodegenerative disorders, such as Hunter syndrome,or sensory motor neuropathies, such as Friedreich ataxia and Charcot-Marie-Tooth syndrome. 

▪ Culture-positive postnatal infections associated with sensorineural hearing loss, including confirmed bacterial and viral (especially herpes viruses and varicella) meningitis.

▪ Head trauma, especially basal skull/temporal bone fracture§ that requires hospitalization.

▪ Chemotherapy.


(920 AMERICAN ACADEMY OF PEDIATRICS APPENDIX 2: RISK INDICATORS ASSOCIATED WITH PERMANENT CONGENITAL, DELAYED-ONSET, OR PROGRESSIVE HEARING LOSS IN CHILDHOOD)

**USDB has audiometers available for loan to complete these screeners.  Please contact audiology@usdb.org in your area to reserve an audiometer and receive training on how to use this screening tool.**

Submit
Never submit passwords through Google Forms.
This form was created inside of Utah Schools for the Deaf and the Blind. Report Abuse - Terms of Service