CHILD AND ADOLESCENT HEALTH
Equipment Label
CALIBRATION SITE/DATE__________________________________________________________________________________________________
Place √ mark before the machine to be serviced: _____AUDIOMETER _____TYMPANOMETER_____ AUDIOMETER/TYMP COMBINATION
_____OTOACOUSTIC EMISSIONS (OAE) ______ OAE/TYMP COMBINATION
Make ______________________________ Model# ________________________Serial__________________________________
I authorize the following services on-site: (Place √ before the desired service)
______ Calibration check-up for Audiometer______ Full Audiometer calibration, if needed
______ Full Tympanometer calibration, even if only non-screened frequencies are out of specification: Yes_ or _No
______ Full Otoacoustic Emissions (OAE) calibration (some cannot be calibrated, you will be notified if applicable)
Authorized Signature__________________________________________________________________________________________________
Name/School (including ISD#)/Clinic/Agency
_________________________________________________________________________________________________________
Email Address
_________________________________________________________________________________________________________
Address
Bill to if different than
above____________________________________________________________________________________________________
Agency Name/Address
Purchase Order # __________________________________________________ Date: _________________________________
Equipment Label
CALIBRATION SITE/DATE__________________________________________________________________________________________________
Place √ mark before the machine to be serviced: _____AUDIOMETER _____TYMPANOMETER_____ AUDIOMETER/TYMP COMBINATION
_____OTOACOUSTIC EMISSIONS (OAE) ______ OAE/TYMP COMBINATION
Make ______________________________ Model# ________________________Serial__________________________________
I authorize the following services on-site: (Place √ before the desired service)
______ Calibration check-up for Audiometer______ Full Audiometer calibration, if needed
______ Full Tympanometer calibration, even if only non-screened frequencies are out of specification: Yes_ or _No
______ Full Otoacoustic Emissions (OAE) calibration (some cannot be calibrated, you will be notified if applicable)
Authorized Signature__________________________________________________________________________________________________
Name/School (including ISD#)/Clinic/Agency
_________________________________________________________________________________________________________
Email Address
_________________________________________________________________________________________________________
Address
Bill to if different than
above____________________________________________________________________________________________________
Agency Name/Address
Purchase Order # __________________________________________________ Date: _________________________________