2 CDC EHDI Hearing Screening and Follow-up Survey (HSFS)

Early Hearing Detection and Intervention Hearing Screening and Follow-up survey

Attach_4B_EHDI_Survey

CDC EHDI Hearing Screening and Followup Survey (HSFS)

OMB: 0920-0733

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Attachment 4B


Form Approved

OMB No. 0920-0733

Exp. Date XX/XX/XXXX


CDC EHDI Hearing Screening and Follow-up Survey (HSFS)


































The public reporting burden of this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0733)

Part 1: Screening, Diagnostic, and Intervention Data

Hearing Screening Diagnostic Intervention Type/Severity Finalize



Calculate Totals (yellow fields)





2009 Documented Hearing Screening Data

Data Item

Value

Total Occurrent Births


Total Occurrent Births According to Vital Records


Total Occurrent Births at Military Facilities According to Vital Records (enter “0” if no births reported or “none” if there are no military hospitals)


Total Occurrent Births at Military Facilities for which Hearing Results were Reported to the EHDI Program

(enter “0” if no births reported or “none” if there are no military hospitals)


Hearing Screening

Total Documented as Screened

(automatically calculated)*

Total Documented as Not Screened

(automatically calculated)*

Infant Died


Parents / Family Declined Services


Missed


Unknown


Passed (final screen)

Total Pass

(automatically calculated)*

Pass Before 1 Month of Age


Pass After 1 month but Before 3 Months of Age


Pass After 3 Months of Age


Pass: Age Unknown


Not Passed (final screen)

Total Not Pass

(automatically calculated)*

Not Pass Before 1 Month of Age


Not Pass After 1 month but Before 3 Months of Age


Not Pass After 3 Months of Age


Not Pass: Age Unknown


Inpatient (IP) /Outpatient (OP) Screening Protocol Only:

Not Pass initial/IP screen, and did not receive a rescreen/OP screen or a documented diagnosis




Total Occurrent Births (automatically calculated)*

(automatically calculated)*



































Notes*

  • Total Occurrent Births (automatically calculated)” is based on the sum of the values for “Total Screened” and “Total Not Screened.”

  • The value calculated for “Total Occurrent Births (automatically calculated)” should match the value entered for “Total Occurrent Births” at the top of this page. If there is any difference between these values you will receive an error message.



Hearing Screening Diagnostic Intervention Type/Severity Finalize




Calculate Totals (yellow fields)


2009 Documented Diagnostic Data

Data Item

Value

Total Not Pass Screening

(from Screening section)

No Documented Hearing Loss

Total with No Hearing Loss


No Hearing Loss Before 3 Months of Age


No Hearing Loss After 3 Months but Before 6 Months of Age


No Hearing Loss After 6 Months of Age


No Hearing Loss Documented: Age Unknown


Documented Permanent Identified (ID) Hearing Loss

Total Hearing Loss

(automatically calculated)*

Hearing Loss ID: Before 3 Months of Age


Hearing Loss ID After 3 Months but Before 6 Months of Age


Hearing Loss ID After 6 Months of Age


Hearing Loss ID: Age Unknown


No Documented Diagnosis / Undetermined

Total with No Diagnosis

(automatically calculated)*

Audiologic Diagnosis in Process (Awaiting Diagnosis)


Non-resident or Moved Out of Jurisdiction


Infant Died


Parents / Family Declined Services


Parent / Family Contacted but Unresponsive


Unable to Contact


Unknown




Total Not Pass

(automatically calculated)*


Note: Only cases of hearing loss that were not reported in the above Diagnostics Section (e.g., cases of late-onset hearing loss) should be reported in the below “Hearing Loss not included in above Permanent Identified (ID) Hearing Loss” section.


Hearing Loss not included in above “Permanent Identified (ID) Hearing Loss”

(e.g., Cases of permanent late onset hearing loss)

Hearing Loss ID: Before 3 Months of Age


Hearing Loss ID After 3 Months but Before 6 Months of Age


Hearing Loss ID After 6 Months of Age


Hearing Loss ID: Age Unknown


Total Cases of Hearing Loss (not included above)

(automatically calculated)*

Documented Cases of Non-Permanent ID Hearing Loss

Cases of non-permanent, transient hearing loss ID







C

Hearing Screening Diagnostic Intervention Type/Severity Finalize

alculate Totals (yellow fields)


2009 Documented Intervention Data

Data Item

Value

Total Cases Hearing Loss

(from Diagnostic section)

Referrals to Part C Early Intervention (EI)

Total Referrals to Part C EI

(automatically calculated)*

Referred and Eligible for Part C EI


Referred and Not Eligible for Part C EI


Referred but Eligibility Unknown


Not Referred to Part C EI and Unknown




Total Referred, Not Referred, and Unknown

(automatically calculated)*

Enrolled in Part C Early Intervention (EI)

Total Enrolled in Part C EI

(automatically calculated)*

Enrolled Before 6 Months of Age


Enrolled After 6 Months but Before 12 Months of Age


Enrolled After 12 Months of Age


Enrolled: Age Unknown


Monitoring Services

Receiving Only Monitoring Services


Receiving ONLY Intervention Services from Non Part C EI

Total Services from Non-Part C EI services Only

(automatically calculated)*

Services Before 6 Months of Age


Services After 6 Months but Before 12 Months of Age


Services After 12 Months of Age


Services: Age unknown


No Intervention Services

Total No Services

(automatically calculated)*

Not Eligible for Services


Infant Died


Parents / Family Declined Services


Non-resident or Moved Out of Jurisdiction


Parent / Family Contacted but Unresponsive


Unable to Contact


Unknown


Total Intervention & No Services

(automatically calculated)*


Cases of Hearing Loss not included in the above “Intervention” Section

(e.g., Cases of late onset hearing loss)

Hearing Loss Not included in above “Total Hearing Loss”

(From Diagnostics Section)

Total Enrolled in Part C EI


Total Services from Non-Part C EI services


No Intervention: Monitoring Only


No Intervention: Unknown


P

Hearing Screening Diagnostic Intervention Type/Severity Finalize

art 2: Type and Severity of Identified Hearing Losses (2009)



Total Cases of Permanent Hearing Loss

(from Diagnostic section of Part 1)



Calculate Totals (yellow fields)




BILATERAL

UNILATERAL

LATERALITY UNKNOWN

(for CASES where it is unknown if the loss is unilateral or bilateral)





 

 

RIGHT EAR

LEFT EAR

UNKNOWN EAR (Note: record degree of loss for each ear)

RIGHT EAR

LEFT EAR

UNKNOWN EAR


Sensorineural

Mild

 

 

 

 

 

 

 


Moderate

 

 

 

 

 

 

 

 

Severe

 

 

 

 

 

 

 

 

Profound

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

Conductive

Mild

 

 

 

 

 

 

 

 

Moderate

 

 

 

 

 

 

 

 

Severe

 

 

 

 

 

 

 

 

Unknown Severity

 

 

 

 

 

 

 

 

Mixed

Mild

 

 

 

 

 

 

 

 

Moderate

 

 

 

 

 

 

 

 

Severe

 

 

 

 

 

 

 

 

Profound

 

 

 

 

 

 

 

 

Unknown Severity

 

 

 

 

 

 

 

 

Type Unknown

Mild

 

 

 

 

 

 

 

 

Moderate

 

 

 

 

 

 

 

 

Severe

 

 

 

 

 

 

 

 

Profound

 

 

 

 

 

 

 

 

Unknown Severity

 

 

 

 

 

 

 

 

Auditory Neuropathy

Mild

 

 

 

 

 

 

 

 

Moderate

 

 

 

 

 

 

 

 

Severe

 

 

 

 

 

 

 

 

Profound

 

 

 

 

 

 

 

 

Unknown Severity

 

 

 

 

 

 

 

 


Totals by Ear*

0

0

0

0

0

0

0

0

Totals by Child








Note*: The above totals will be automatically calculated and compared to the total number of hearing loss cases reported in the Diagnostics Section of Part 1

P

Screening Demographics Diagnostics Demographics Intervention Demographics Finalize

art 3: Demographics


Screening

Diagnostics

Intervention


Total Occurrent Births

Total Pass

Total Pass Before 1 Month

Total Not Pass

Total Not Pass Before 1 Month

Normal Hearing

Normal Hearing Before 3 Months

Hearing Loss

Hearing Loss Before 3 Months

Total Enrolled in Part C EI*

Total Enrolled in Part C EI* Before 6 Months

Total Services Non-Part C EI*

Total Services Non-Part C EI*Before 3 Months

Totals (from Part 1)














Sex














Male














Female














Unknown














Totals (auto calculated)














Maternal Age














<15 years














15-19 years














20 – 24 years














25-34 years














35 – 50 years














> 50 years














Unknown














Totals (auto calculated)














Mothers Education














Less than High School














High School Graduate or GED














Some College or AA/AS degree














College Graduate or above














Unknown














Totals (auto calculated)














Maternal Ethnicity














Hispanic or Latino














Not Hispanic or Latino














Unknown














Totals (auto calculated)














Maternal Race














White (Not Hispanic)














White (Hispanic)














White (Ethnicity Unknown)














Black or African American (Not Hispanic)














Black or African American (Hispanic)














Black or African American (Ethnicity Unknown)














Asian














Native Hawaiians & other Pacific Islanders














American Indian & Alaska Natives














Unknown














Other














Totals (auto calculated)
















Hearing Screening Diagnostic Intervention Type/Severity Finalize


Dear Respondent:


Thank you for completing this survey Please enter any comments and/or caveats about the data reported in the below Comments section. To submit the survey please click the red “Submit Survey” button that is located below the Comments box.




Comments








 

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