Fillable HEARING AND VISION QUESTIONNAIRE FORM 05aug21

Fill Online, Printable, Fillable, Blank HEARING AND VISION QUESTIONNAIRE FORM 05aug21 Form

Use Fill to complete blank online OTHERS (US) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

HEARING AND VISION QUESTIONNAIRE FORM 05aug21

On average this form takes 22 minutes to complete

The HEARING AND VISION QUESTIONNAIRE FORM 05aug21 form is 4 pages long and contains:

  • 0 signatures
  • 141 check-boxes
  • 22 other fields

Country of origin: US
File type: PDF

BROWSE OTHERS (US) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HEARING AND VISION QUESTIONNAIRE FORM
HEARING & VISION
QUESTIONNAIRE
SECTION 1: CHILD AND SERVICE COORDINATOR INFORMATION
Child’s First and Last Name:
Date of Birth:
Date:
BRIDGES ID:
Name: Intake Coordinator Service Coordinator
Agency:
Purpose:
Eligibility Determination/
Initial IFSP
1st Annual IFSP
2nd Annual IFSP
SECTION 2: HEARING
*These questions can be asked at any review but
are required as indicated
at the intake and with each annual review of the IFSP.
2.A. SCREENING: INTAKE COORDINATOR AND SERVICE COORDINATOR
In the last six months, has the child had a hearing screening, including a Newborn Hearing Screening due to a hearing
concern?
NO: Proceed with BabyNet eligibility evaluation or assessment of child’s unique strengths and needs and confirm
with parent or caregiver that child is not yet due for an audiological follow-up.
YES: Normal: If “yes/normal,” proceed with BabyNet eligibility evaluation or assessment of child’s unique
strengths and needs
YES: Abnormal: If “yes/abnormal,” a consultation with an SCSDB Regional Services Coordinator is required
before completing the BabyNet eligibility evaluation or assessment of child’s unique strengths and needs.
Name of Audiologist/ENT:
Date of contact with SCSDB Regional Services Coordinator:
SCSDB Regional Services Coordinator’s Name:
Consultation results:
2.B. ESTABLISHED RISK CONDITIONS FOR HEARING: INTAKE COORDINATOR
The following conditions are diagnosed by a physician.
If any box is checked, the child is automatically eligible for
IDEA/Part C services. Service Coordination must be provided by SCSDB.
Agenesis of corpus callosum
Hearing loss > 20 dB
Auditory atresia
Microtia
Auditory neuropathy
Stickler syndrome
Branchiootorenal (BOR)/Meinick-Fraser
Waardenburg syndrome
Other:
SCDHHS/IDEA PART C/01AUG2021/ALL PREVIOUS VERSIONS ARE VOID
SCDHHS/IDEA PART C/01AUG2021/ALL PREVIOUS VERSIONS ARE VOID
HEARING AND VISION QUESTIONNAIRE FORM
2.C. HIGH RISK FACTORS ASSOCIATED WITH HEARING LOSS.
If any box below is checked, the parent should be
encouraged to discuss concerns with primary care physician. A consultation with an SCSDB Regional Services
Coordinator is required before completing the IDEA/Part C initial or annual eligibility evaluation, or assessment
of child’s unique strengths and needs.
2.C.1.
MEDICAL FACTORS ASSOCIATED WITH HEARING LOSS: INTAKE COORDINATOR & SERVICE COORDINATOR
INTAKE COORDINATOR
SERVICE COORDINATOR
APGAR score of 3 or less (at 5 minutes after birth)
Excessive discharge from the ears
Excessive discharge from the ears
Head trauma
Family history of hearing loss
Meningitis
Head trauma
Otitis media (recurring earaches or ear infections)
Hyperbilirubinemia level (jaundice) requiring
transfusion
Prolonged medical ventilation (more than 10 days)
Meningitis
Seizures
More than one course of ototoxic medication
Other:
Otitis media (recurring earaches or ear infections)
Prenatal exposure to maternal drug abuse
Prenatal exposure to maternal infections (e.g.,
toxoplasmosis, syphilis, rubella, cytomegalovirus,
herpes)
Prolonged medical ventilation (more than 10 days)
Seizures or neurodegenerative disorder (e.g.,
mitochondrial disease)
Other:
2.C.2. SYNDROMES/CONDITIONS ASSOCIATED WITH HEARING LOSS: INTAKE COORDINATOR
CHARGE Syndrome
Shaken Baby Syndrome
Congenital Brain Malformation
Smith-Magenis Syndrome
Cytomegalovirus (CMV)
Trisomy 13
Dandy Walker Syndrome
Trisomy 18
Down Syndrome
Turner Syndrome
Fetal Alcohol Syndrome
Williams Syndrome)
Osteogenesis Imperfecta
Wolfe-Hirschhorn Syndrome
Prader-Willi Syndrome
Other:
2.C.3.
PHYSICAL APPEARANCE ASSOCIATED WITH HEARING LOSS:
INTAKE COORDINATOR
Cleft lip and palate
Cranio-facial anomalies
2.C.4
.
ATYPICAL BEHAVIORS ASSOCIATED WITH HEARING LOSS:
INTAKE COORDINATOR & SERVICE COORDINATOR
Atypical vocal behaviors
Makes few or inconsistent responses to sounds
Frequently does not respond to caregivers calling
his/her name
Pulls on ears or puts hands over ears
Has an abnormality in voice, intonation (pitch), or
articulation
Shows a delay in language development
Has limited vocalizations
Shows a preference for certain types of sounds
SECTION 3: VISION
*These questions can be asked at any review but
are required as indicated
at the intake and with each annual review of the IFSP.
3.A. SCREENING: INTAKE COORDINATOR & SERVICE COORDINATOR
In the last six months, has the child had a vision screening due to a vision concern?
NO: Proceed with BabyNet eligibility evaluation or assessment of child’s unique strengths and needs and confirm
with parent or caregiver that child is not yet due for an ophthalmological follow-up.
YES: Normal: If “yes/normal,” proceed with BabyNet eligibility evaluation or assessment of child’s unique
strengths and needs
YES: Abnormal: If “yes/abnormal,” a consultation with an SCSDB Regional Services Coordinator is required
before completing the BabyNet eligibility evaluation or assessment of child’s unique strengths and needs.
HEARING AND VISION QUESTIONNAIRE FORM
Name of ophthalmologist:
Date of contact with SCSDB Regional Services Coordinator:
SCSDB Regional Services Coordinator’s Name:
Consultation results:
3.B. ESTABLISHED RISK CONDITIONS FOR VISION: INTAKE COORDINATOR
The following conditions are diagnosed by a physician.
If any box is checked, the child is automatically eligible for
IDEA/Part C services. Service Coordination must be provided by SCSDB.
Albinism
Glaucoma w/ visual impairment
Anophthalmia
Lebers amaurosis
Bilateral optic nerve coloboma
Mobius syndrome
Bilateral retinal detachment w/ blindness
Optic nerve atrophy
Bilateral visual acuity < 20/70 corrected vision best eye
Retinitis pigmentosa
Cataracts w/ visual impairment
Retinoblastoma
Coloboma/keyhole pupil
ROP stages 4 and 5
Cortical blindness
Septo-optic dysplasia
Other:
3.C. HIGH RISK FACTORS ASSOCIATED WITH VISION LOSS.
If any box below is checked, the parent should be
encouraged to discuss concerns with primary care physician. A consultation with an SCSDB Regional Services
Coordinator is required before completing the IDEA/Part C initial or annual eligibility evaluation, or assessment
of child’s unique strengths and needs.
3.C.1. MEDICAL FACTORS ASSOCIATED WITH VISION LOSS:
INTAKE COORDINATOR & SERVICE COORDINATOR
INTAKE COORDINATOR
SERVICE COORDINATOR
APGAR score of 3 or less (at 5 minutes after birth)
Constant tears (when child is not crying)
Constant tears (when child is not crying)
Head trauma
Head trauma
Meningitis
Meningitis
Prolonged medical ventilation (more than 10 days)
Prenatal exposure to maternal drug abuse Prolonged
medical ventilation (more than 10 days)
Seizures or neurodegenerative disorder (i.e.
mitochondrial disease)
Prenatal exposure to maternal infections
(toxoplasmosis, syphilis, rubella, cytomegalovirus,
herpes)
Other:
Prolonged medical ventilation (more than 10 days)
Seizures or neurodegenerative disorder (i.e.
mitochondrial disease)
Other:
3.C.2. SYNDROMES/CONDITIONS ASSOCIATED WITH VISION LOSS:
INTAKE COORDINATOR
CHARGE Syndrome
Shaken Baby Syndrome
Congenital Brain Malformation
Smith-Magenis Syndrome
Cytomegalovirus (CMV)
Trisomy 13
SCDHHS/IDEA PART C/01AUG2021/ALL PREVIOUS VERSIONS ARE VOID
HEARING AND VISION QUESTIONNAIRE FORM
Dandy Walker Syndrome
Trisomy 18
Down Syndrome
Turner Syndrome
Fetal Alcohol Syndrome
Williams Syndrome)
Osteogenesis Imperfecta
Wolfe-Hirschhorn Syndrome
Prader-Willi Syndrome
Other:
3.C.3. PHYSICAL APPEARANCE ASSOCIATED WITH VISION LOSS:
INTAKE COORDINATOR & SERVICE COORDINATOR
Absence of a clear black pupil
Constant inflamed, encrusted, or watery eyes (infections occur often)
Constant redness of the white conjunctiva
Constant swelling of the eyes
Eyes appear crossed to cross or turn outward, inward, upward, or downward
Eyes do not move in together or in unison
Hazy cornea or whitish pupil
Horizontal or vertical rapid eye movements (nystagmus)
Sagging of an eyelid that blocks the pupil
Visible changes to or irregularities in the shape, size, or structure of the eyes
3.C.4. ATYPICAL BEHAVIORS ASSOCIATED WITH VISION LOSS:
INTAKE COORDINATOR & SERVICE COORDINATOR
Absence of eye contact (by age 3 months)
Cannot find dropped toy
Does not notice people or objects when placed in certain areas
Does not reach or inaccuracy when reaching for toys/objects
Eye poking, rocking, or staring at lights
Eyes burn, itch, or feel scratchy
Great discomfort in reaction to bright light (photophobia)
Over or under reaches on curbs or steps
Poor visual fixation or tracking (by age 3 months)
Sleeps for short times only, and then wakes up rubbing eyes and/or complaining of pain in the eyes
Squints eyes when outside or inside
Tilts head when looking
SCDHHS/IDEA PART C/01AUG2021/ALL PREVIOUS VERSIONS ARE VOID
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

HEARING AND VISION QUESTIONNAIRE FORM 05aug21

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document