Mock hearing & vision submission form. Screener Name * First Name Last Name School * Date MM DD YYYY Round 1 Round 2 Thank you! Student Name * First Name Last Name HEARING SCREENING Known Hearing Impairment Complete this section only if the student has been medically diagnosed with a hearing impairment or has been prescribed the use of a hearing aid. R L RL 500Hz / 1000z / 2000Hz / 4000Hz Chart * P F U D OAE was used to screen the child The child verbalized or displayed an illness or infection. Responses were not consistent and / or there were other conditions that may have adversely affected the test results Notes VISION SCREENING Known Vision Impairment Complete this section only if the student has been medically diagnosed with a vision impairment or has been prescribed glasses or contacts. Wears Glasses / Contacts Does Not Wear / Lost / Broken Glasses / Contacts Results * P F U D Notes Color Vision 1st & 2nd Grade Boys Only P F U D Thank you!
