HLT614 – Hearing Screening Program Report

As of date:

Date to report.

Screening Performed By:

Enter a value that will display on the report output.

Screener(s) attach copy of hearing certificate:

Marks the coordinating check box on the report output.

Report Completed By:

Enter a value that will display on the report output.

Title:

Enter a value that will display on the report output.

Equipment Calibration Date:

Date Equipment was calibrated.

ADHS Equipment was used:

Marks the coordinating check box on the report output.

Audiologist’s Phone Number:

Enter a value that will display on the report output.

Audiologist-Fill in License #:

Marks the coordinating check box on the report output.

Audiologist’s License #:

Enter a value that will display on the report output.

Audiometer used for grades:

Marks the coordinating check box on the report output.

Tympanometer used for grades:

Marks the coordinating check box on the report output.

OAE used for grades:

Marks the coordinating check box on the report output.

Reason Codes of records that count as not screened:

Filters report output.

Result Codes for records that count as failed:

Filters report output.