Attach_5

Early Hearing Detection and Intervention

Hearing Screening and Follow-up Survey

Reinstatement with Change

Marcus Gaffney

Project Officer

1600 Clifton Rd. MS E-88

Atlanta, GA 30333

(404) 498-3031

[email protected]

Attachment 5:

DSHPSHWA Annual Survey

The Directors of Speech and Hearing Programs in State Health and

Welfare Agencies (DSHPSHWA) Data Reporting Form

State/Territory Reporting:    Reporting Year:   

1) Are birthing hospitals/facilities/providers required by the state to report hearing screening information? Yes No

1. If “yes” to question #1, what information are hospitals/facilities/providers required to report?      

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Screening Information

2) Number of Live Births (in year 2003):       Act Est

 Source of the data (i.e. state report?):      

1. Total Number of infants born between 1/01/03 – 12/31/03 screened for hearing loss:      

Act Est

1. Number screened prior to discharge (if known):       Act Est

2. Number screened after discharge, but before 1 month of age (if known):       Act Est

 Source of the data:      

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Referral Information

4) Number of infants born between 1/01/03 – 12/31/03 referred for a Diagnostic Audiologic Evaluation:       Act Est

 Source of the data:      

5) Number of infants born between 1/01/03 – 12/31/03 received a Diagnostic Audiologic Evaluation:       Act Est

a) Number of infants receiving a Diagnostic Audiologic Evaluation before 3 months of age:       Act Est

 Source of the data:      

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Case Information

6) Total number of children born between 1/01/03 – 12/31/03 who were identified with a Permanent Childhood Hearing Loss (PCHL) (including both those identified through a newborn hearing screening program and late identified cases):       Act Est

1. Of the total number of children born between 1/01/03 – 12/31/03 who were identified with a PCHL, how many were screened through a Newborn Hearing Screening Program:       Act Est

7) Average, Median, and Age Range of Children when they are diagnosed with a PCHL:

a) Average Age (Months):      c) Minimum Age (Months)     

b) Median Age (Months):      d) Maximum Age (Months)     

Average Age: If there are 5 children born in 2003 with a PCHL with the following age of diagnosis: 1.00 month, 1.25 months, 3.75 months, 4.50 months, 6.25 months, the average for 2003 would be:1.00 + 1.25 + 3.75 + 4.50 + 6.25 = 16.75 divided by 5 = 3.35 months. Median Age: Using these ages, the median age for 2003 would be 3.75 months (age when 50% of children are above & 50% are below).

Did your state use the DSHPSHWA formula (DSHPSHWA Explanations) to determine the previous values: Yes No

 If you answered no, please explain:      

8) Total number of children born in 2003 with PCHL receiving intervention:       Act Est

a) Number born in 2003 with PCHL that received intervention before 6 Months of age:      

Act Est

Intervention: Refers to services specifically for children who are deaf or hard of hearing and may include, but are not limited to monitoring, speech-language therapy, early intervention programming on a regular basis by a parent-infant specialist, medical or surgical treatment, etc (please see DSHPSHWA Explanations for more information).

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Hospital Reporting & State Tracking Information

9) Number of birthing hospitals/facilities:      Act Est 

10) Number of birthing hospitals/facilities with Universal Newborn Hearing Screening (UNHS):     

Act Est 

11) Does your state/territory define a UNHS birthing hospital/facility by the percent of infants screened:

Yes No

a) If yes, please select one of the following choices:

Screen 95% or over Screen 90% or over Screen 85% or over Other (Please

specify)      

12) How do birthing hospitals/facilities report hearing screening information to the state / territory (check all that apply):

Auris Electronic Forms QS Technologies

Blood Spot Card HI*Track Paper Reporting Form(s)

Custom/State Developed Hospitals do not report OZ System

Electronic Birth Certificate (EBC) Other (please specify)      

13) What system, if any, does the state/territory use to track hearing screening and follow-up information for infants/children:

Auris Limelight Technologies None

Custom/State Developed Neometrics OZ System

HI*Track Other (please specify)      

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Top of Form

Hearing Loss Type & Severity

DSHPSHWA uses the following criteria to classify hearing loss:

Mild: 21 – 40dB HL Severe: 71 – 90dB HL

Moderate: 41 – 70dB HL Profound: 91 + dB HL

14) Does your state/territory use the DSHPSHWA system to classify the severity of a hearing loss?

Yes No

 If you answered No to the previous question, please specify the classification criteria used.

Mild (dB):       Severe (dB):      

Moderate (dB):       Profound (dB):      

15) Please complete the following tables if your state/territory recorded the type and severity of hearing loss for children with PCHL in 2003.

UNILATERAL HEARING LOSSES:

SENSORINEURAL (Total #     )				CONDUCTIVE (Total #     )		MIXED (Total #     )
Mild	Moderate	Severe	Profound	Mild	Moderate	Mild	Moderate	Severe	Profound
    	    	    	    	    	    	    	    	    	    

BILATERAL HEARING LOSSES:

SENSORINEURAL (Total #     )				CONDUCTIVE (Total #     )		MIXED (Total #     )
Mild	Moderate	Severe	Profound	Mild	Moderate	Mild	Moderate	Severe	Profound
    	    	    	    	    	    	    	    	    	    

• If your state did not collect the above data, are there any plans to record this data in the future? Yes No

• If you answered Yes, estimated date to begin recording type and severity of identified cases of PCHL:      

Additional Comments:      

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