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

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.

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