EHDI-PALS Facility Survey Opening

Survey Section 1

http://130.111.214.17:8001/EHDIPALS/Survey/EP_SurveyS1.aspx

Form Approved
OMB NO. 0920-XXXX
Exp. Date: xx/xx/xxxx

EHDI-PALS Facility Survey
Welcome: winnie
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Home
EHDI-PALS Facility
Locator
Questions Parents
Have About
Childhood Hearing
Loss

1. EHDI-PALS Early Hearing Detection & Intervention Links to Services
Thank you in advance for taking time to complete the EHDI-PALS directory survey. The information you provide will be
extremely useful to those seeking pediatric audiology services. Your facility’s services and contact information will be
easily accessed via an online website that will be utilized by families, state Early Hearing Detection and Intervention
(EHDI) coordinators, staff at birthing hospitals and physicians.
Please complete the survey as carefully as possible so that your information can be accurately displayed in the online
directory. You will be able to save your survey information and return at a later time to complete your profile if you do not
have all your needed information on hand. It will take approximately 10 to 15 minutes to complete the survey.
NOTE: EHDI-PALS is designed to identify pediatric audiology services for children who are 0 to 5 years of age. Also, only
those facilities where services are provided by licensed audiologists will be included. Please fill out one survey for each
physical location (e.g. if you have two satellite offices you will need to complete two surveys, one for each location).

Questions
Professionals Have
About Childhood
Hearing Loss

Please note that starred (" * ") items require a response.

Other Helpful
Websites

* Does this facility for which you are completing the survey provide services to children under the

Pediatric Audiology
Facilities Enter here
EHDI-PALS
Administrator Log-in
EHDI-PALS Advisory
Group

age of 5?
Yes
No

0%

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Informatics support by the Center for Research and Evaluation/DEBBI

Public reporting burden of this collection of information is estimated to average 1 minute, 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-XXXX)

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9/3/12 4:26 PM