Free 39986.PDF - Indiana

SCHOOL HEARING SCREENING REPORT
State Form 39986 (R / 2-00)

INDIANA STATE DEPARTMENT OF HEALTH Local Liaison Office

School Name

School year of this report

School Corporation

Name of person completing this report

County

Title of person completing this report

City

Telephone number ( )

NOTE: GUIDELINES ON BACK TOTAL NUMBER SCREENED (13-16) POSITIVE FINDINGS REFERRED (17-19) SAW DOCTOR UNDER TREATMENT (20-22) SAW DOCTOR TREATMENT NOT REQUIRED (23-25) * REFERRALS NOT YET COMPLETED (26-28)

GRADE (11-12) Pre-K K 1 4 7 10 Others Totals
Reasons for incomplete referrals:

RETURN TO: INDIANA STATE DEPARTMENT OF HEALTH LOCAL LIAISON OFFICE 2 North Meridian Street 8-B Indianapolis, IN 46204 Telephone: (317) 233-7404 FAX: (317) 233-7761

PLEASE RETURN NO LATER THAN JUNE 1.

GUIDELINES FOR SCHOOL HEARING AND SCREENING REPORT WE ARE AWARE THAT SCHOOL NURSES DO NOT DO THE ACTUAL SCREENING IN MANY SCHOOL CORPORATIONS, HOWEVER, WE WOULD APPRECIATE YOUR COOPERATION IN OBTAINING THE INFORMATION REQUESTED ON THIS FORM. Column 1: Total Number Screened Record the number of students screened in each category. PLEASE NOTE: The law states that grades 1, 4, 7, and 10 must be screened. Students in all other grades are placed in the other category except K and Pre-K . K and Pre-K are special line items since these are critical ages for early case findings. Column 2: Positive Findings Referred Record the number of students who have failed the screening test this year. Column 3: Saw Doctor - Under Treatment Record the number of students, referred this year, from Column 2, who are receiving treatment. Column 4: Saw Doctor, Treatment Not Required Record the number of students, from this year's screening, who were examined by a physician and no treatment was necessary. Column 5: Referrals Not Yet Completed Record the number of students who have not seen a physician or a determined treatment has not been implemented.