Child and Teen Checkups
P.O. Box 64882
St. Paul, MN 55164-0882
651-201-3760
www.health.state.mn.us
Clinic Checklist: Hearing and Vision Screening
Child and Teen Checkups (C&TC)
Hearing Screening
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Hearing History/ Risk Assessment P
 Family history, parent/child concerns- including
language delays
 Joint Commission on Infant Hearing Risk Factors
(www.health.state.mn.us).
 Risk for noise-induced hearing loss for 11-21
years of age
Visual Inspection P
 External
 Internal with otoscope
Pure Tone Audiometry N
 Quiet room, not a high traffic area
Age 3 years and older:
 Screen at these levels in each ear:
 500 Hz at 25 dB
 1000, 2000, and 4000 HZ at 20 dB
 PASS criteria:
 Child responds to all 8 tones
Documentation
 History
 Child’s ability to cooperate
 Response to each level screened
 PASS, Rescreen, or REFER
Audiometer
 MDH recommends audiometers that provide
pure tones at each screening level and allow
manual screening
 Calibrate yearly
 Headphones are specific to audiometer and are
not interchangeable with others
Infection Control
 Clean headphones using alcohol free agent
recommended by manufacturer
Vision Screening
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Perform Plus Lens screening on children age 5 years
& older who pass visual acuity N
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P: Task usually performed by provider
N: Task usually performed by nursing staff
Vision History P
 Family history, parent/child concerns, observed
problems
Ocular Health P
 External inspection
 Pupil light response
 Red reflex
Muscle Balance P
 Observation
 Corneal light reflex
 Unilateral cover or cross cover test – at
near/distance
 Fix and follow
Visual Acuity N
Age 3-6 years:
 Use HOTV or LEA chart (with rectangle borders
around each line) at 10 feet
 Child must match any 4 symbols in order to pass
a line
 PASS criteria:
 10/25 (20/50) (age 3 years)
 10/20 (20/40) (age 4 years)
 10/16 (20/32) (age 5 years)
Or better in each eye with a 1 or no-line
difference in the PASS range
Age 6 years and older:
 Use Sloan at 10 feet
 Can miss two letters on the 20/20, 20/25, or
20/30 lines and still get credit for that line
 PASS criteria:
 20/30 (10/15) or better
 One or no line difference between eyes
(including 20/25 or 10/12.5 line)
Documentation
 History
 Behaviors (e.g. head tilt, squint)
 Results for each eye
 PASS, rescreen or REFER
Revised 3/2016