DCH-0525.pdf
PDF 131 KB Posted
- Attached to
- DCH 0525 NCR
- Solicitation number
- RFQ 171 240000000694 1
- Issued by
- Michigan
About this file
This is a hearing evaluation report form (DCH-0525, Revised 5-23) issued by the Michigan Department of Health and Human Services for use by school districts and health departments. The form serves as a standardized tool for documenting pediatric hearing screening results and related audiological findings. It captures essential patient information including demographic data, test conditions, medical history, and detailed audiogram results across multiple frequencies (250 Hz to 8000 Hz) for both ears using air and bone conduction testing methods. The form includes sections for recording test outcomes such as normal audiograms, known loss under care, otoacoustic emissions results, and preliminary screening outcomes, with designated spaces for referral criteria assessment and classroom recommendations based on test results.
The form establishes referral criteria and strategic seating recommendations for students who meet specified hearing loss thresholds, defined as positioning the child in close proximity to sound sources with visual and auditory classroom access and flexibility to change location as needed. The document includes fields for technician identification, test date, and remarks, and contains a non-discrimination statement affirming that the Michigan Department of Health and Human Services will not exclude individuals or deny benefits based on protected characteristics or unrelated disabilities. This screening tool operates under the authority of Act 368, PA 1978, and appears designed to facilitate systematic hearing health monitoring and appropriate educational accommodations for school-age children.
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Other files
| File | Type | Posted |
|---|---|---|
| standard-contract-terms-short-form (7).docx | DOCX document | |
| DCH 0525 9-24.docx | DOCX document |
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Text version
DCH-0525 (Rev. 5-23) Previous edition obsolete.
DCH-0525, REPORT OF HEARING EVALUATION AND REPORT TO SCHOOL
Michigan Department of Health and Human Services
(Revised 5-23)
Health Department/County
Name Birthdate Male Female Other Parent Phone # Grade
Address City, State, Zip
District/School ID#
History Test Conditions Yes No Quiet 1 2 3 4 5 Noisy Cold at Time of Test Earaches Child's Response Medical Attention for Ears Sure 1 2 3 4 5 Not Sure
AUDIOGRAM - Frequencies in Hertz Outcome 250 500 1000 2000 4000 8000
Normal Audiogram Right Ear Air Known Loss Under Care Unmasked Bone UTS (unable to screen) Medical Referral (see below) Left Ear Air
MDHHS Referral Criteria met Hearing Level in Decibel (A.N.S.I. 1969) Air Conduction; R or L Air/Bone Gap Otoacoustic Emissions Preliminary Screening/Outcome Difference Between Ears Pass R L Pass R L History Refer R L Refer R L Date______
Classroom Recommendations If the audiogram meets any of the above Referral Criteria, Strategic Seating is recommended.
This is defined as:
1. Child sitting in close proximity to sound source.
2. Child should have visual and auditory access to classroom activities.
3. Child should be allowed to change location within the classroom to facilitate best auditory access.
Remarks
Date Test Number Technician
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.
AUTHORITY: ACT 368, PA 1978.
File details come from the government source that posted it. Updated .