DCH-0525.pdf
PDF 133 KB Posted
- Solicitation number
- RFQ 171 260000000483 1
- Issued by
- Michigan
About this file
This is a standardized hearing evaluation and reporting form issued by the Michigan Department of Health and Human Services, designed to document audiological assessments and communicate results to schools. The form serves as both a clinical record and an official report mechanism for school health departments and county health agencies conducting hearing screenings on students. The document captures comprehensive audiometric data including test conditions, patient history, and hearing outcomes across multiple frequencies (250 to 8000 Hertz) for both air and bone conduction testing. Results are classified as normal audiograms, known loss under care, or medical referrals based on established MDHHS referral criteria, with notations for otoacoustic emissions and cases where screening cannot be completed.
The form includes clinical recommendations for classroom accommodations when audiogram results meet referral criteria, specifically strategic seating protocols that position students in close proximity to sound sources and allow visual and auditory access to classroom activities. The document authorizes technicians to document observations regarding test conditions (quiet or noisy environments), medical history related to ear health, and the child's cooperation during assessment. The form incorporates non-discrimination language affirming compliance with state law regarding protected classes, and authority is established under Michigan Public Act 368 of 1978. This standardized reporting mechanism enables school systems to implement evidence-based accommodations and track referrals for further medical evaluation when indicated by audiometric findings.
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Other files
| File | Type | Posted |
|---|---|---|
| Standard Contract Terms - Short Form.pdf | ||
| DCH 0525 Report of Hearing Evaluation and Report to School BID REQUEST 10-26.docx | DOCX document | |
| State of Michigan Print Mail Management Terms Conditions (1).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 .