Early Childhood Screening Hearing Worksheet
Name
Screen Date
Age at Screen (Years and Months)
Rescreen Date
Age at Rescreen (Years and Months)
Problem noted check box (when indicated):
No
Yes
No
Yes
Risk factors and hearing history
Developmental surveillance and screening
Visual inspection/Otoscopy (all ages)
Pure tone (3 years +)
Tympanometry perform for REFER results on pure tone
audiometry screening
Visual Inspection
The results of the screening indicate (circle one) PASS /REFER
Initial screen
Rescreen
External inspection
PASS
REFER
PASS
REFER
Internal inspection /Otoscopy
PASS
REFER
PASS
REFER
Comments (if inspection is REFER):
Pure Tone Audiometry
screen
Right ear
The results of the screening indicate (circle one) PASS /REFER
25dB, 500 Hz
PASS
REFER
20dB, 1000 Hz
PASS
PASS
REFER
20dB, 2000 Hz
PASS
PASS
REFER
20dB, 4000 Hz
PASS
PASS
REFER
PASS
Left ear
25dB, 500 Hz
PASS
REFER
20dB, 1000 Hz
PASS
PASS
REFER
20dB, 2000 Hz
PASS
PASS
REFER
20dB, 4000 Hz
PASS
PASS
REFER
REFER
PASS
REFER
(Reviewed/Revised 3/2014)
Pure Tone Audiometry
Rescreen
Right ear
The results of the screening indicate (circle) PASS/REFER
25dB, 500 Hz
PASS
REFER
20dB, 1000 Hz
PASS
PASS
REFER
20dB, 2000 Hz
PASS
PASS
REFER
20dB, 4000 Hz
PASS
PASS
REFER
PASS
Left ear
25dB, 500 Hz
PASS
REFER
20dB, 1000 Hz
PASS
PASS
REFER
20dB, 2000 Hz
PASS
PASS
REFER
20dB, 4000 Hz
Tympanometry
Immediate rescreen
Later rescreen: date
Threshold Screening
Right ear
PASS
REFER
PASS
The results of the screening indicate (circleREFER
one) PASS/REFER
PASS
PASS
REFER
REFER
PASS
REFER
As indicated for referral and follow-up
Write in decibel (dB) heard
500 Hz
1000 Hz
2000 Hz
4000 Hz
8000 Hz
Left ear
Write in decibel (dB) heard
500 Hz
1000 Hz
2000 Hz
4000 Hz
8000 Hz
Maternal and Child Health Section
th
85 East 7 Place
St. Paul, MN 55101
(651) 201-3760
(Reviewed/Revised 3/2014)