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

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 4B:

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

Form Approved

OMB No. 0920-0733

Exp. Date XX/XX/XXXX

2013 CDC EHDI

Hearing Screening and Follow-up Survey (HSFS)*

Note: Please select the Type and Severity system that was used to classify cases of permanent hearing loss for infants born in calendar year 2011 before clicking the "Begin Survey" button. You will not be able to begin the survey until you select either the “ASHA” or “DSHPSHWA” option

Please select type and severity system first!

ASHA system

DSHPSHWA system

Directions

Please complete the following survey with only documented, non-estimated data for infants born between January 1, 2012 and December 31, 2012. Any comments and/or caveats about the reported data can be entered in the Comments section at the end of the survey.  If you have any questions about this survey please refer to the explanations document or contact Marcus Gaffney at: [email protected] / (404) 498-3031.

Survey Explanations

Survey Notes

• The survey is divided into three parts, which each have several different sections. These include Part 1 (Hearing Screening, Diagnostic, and Early Intervention), Part 2 (Type and Severity), and Part 3 (Demographics). Part 3 can only be completed after Parts 1 and 2 have been submitted.

• Data cannot be manually entered into fields highlighted in yellow. The totals for these yellow fields will be automatically calculated based on the data entered into the non-highlighted fields. These calculated values will appear in the yellow boxes after selecting the "Calculate Totals" button near the top of each survey page.

• To navigate through the survey use the menu bar located near the top of each survey page and click on the desired section (e.g., Diagnostic).

Burden Notice: 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)

Note*: This document is intended for informational purposes only. While this document closely resembles the online HSFS there are some formatting differences.

Part 1: Screening, Diagnostic, and Intervention Data

Calculate Totals (yellow fields)

2012 Documented Hearing Screening Data
Total Occurrent Births
Total Occurrent Births According to Vital Records
Optional: Number of infants in the NICU >5 days?
Optional: Total Occurrent Births at Military Facilities According to Vital Records (enter “none” if there are no military hospitals)
Optional: Total Occurrent Births at Military Facilities with Hearing Screening Results Reported to the EHDI Program (enter “none” if there are no military hospitals)
Hearing Screening
Total Documented as Screened	(automatically calculated)
Passed (most recent/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
NICU Infants (>5 days): Pass
Not Passed (most recent/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
NICU Infants (>5 days): Not Pass
Optional: Inpatient (IP) /Outpatient (OP) Screening Protocol Only
Not Pass IP screen and did not Receive an OP Screen
No Documented Hearing Screening
Total Documented as Not Screened	(automatically calculated)
Infant Died
Non-resident
Unable to be Screened due to Medical Reasons
Parents / Family Declined Services
Infant Transferred and No Documentation of Screening
Missed
Unknown
Total Occurrent Births*	(automatically calculated)

Notes*

• The field “Not Pass IP screen and did not Receive an OP Screen” is not included in the calculation of “Total Occurrent Births (automatically calculated)”

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

Calculate Totals (yellow fields)

2012 Documented Diagnostic Data
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) Requirement: Only infants seen at least one time and have a follow-up appointment scheduled
Non-resident
Moved Out of Jurisdiction
Infant Died
Unable to Receive Diagnostic Testing due to Medical Reasons
PCP did not Refer Infant for Diagnostic Testing
Parents / Family Declined Services
Parent / Family Contacted but Unresponsive
Unable to Contact
Unknown
Total Not Pass*	(automatically calculated)

Optional: Other Documented Cases of ID Hearing Loss
Cases of non-permanent, transient hearing loss ID
Permanent cases of hearing loss among infants reported as Non-Residents
Permanent cases of hearing loss among infants that are residents but were born in a different jurisdiction

Note*

• The value for “Total Not Pass (automatically calculated)” must match the value listed for “Total Not Pass Screening” at the top of this page. If there is any difference you will receive an error message.

Calculate Totals (yellow fields)

20112Documented Intervention Data
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
Optional: Referred to Part C EI Before Six Months of Age
Total Referred, Not Referred, and Unknown	(automatically calculated)
Enrolled in Part C 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 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 Part C Services
Infant Died
Parents / Family Declined Services
Non-resident
Moved Out of Jurisdiction
Parent / Family Contacted but Unresponsive
Unable to Contact
Unknown
Total Intervention & No Services*	(automatically calculated*)

Notes*

• The value for “Referred to Part C EI Before Six Months” is not included in any automatically calculated totals.

• The value for “Total Intervention & No Services” must match the value listed for “Total Cases Hearing Loss” at the top of this page. If there is any difference you will receive an error message.

Additional Cases Not Reported

Notes*

• Only cases of hearing loss not reported in the previous Diagnostics section should be reported in the below “Hearing Loss not included in above Permanent Identified (ID) Hearing Loss” section.

• Only cases of hearing loss not reported in the previous Intervention section should be reported in the below “Hearing Loss not included in above Permanent Identified (ID) Hearing Loss” section.

Hearing Loss Cases not included in “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)

Cases of Hearing Loss not included in the “Intervention” Section (e.g., Cases of late onset hearing loss)
Total Cases of Hearing Loss (not included above)
Total Enrolled in Part C EI
Total Services from Non-Part C EI services
No Intervention: Monitoring Only
No Intervention: Unknown
Hearing Loss Not included in above “Intervention” Section	(automatically calculated)

Part 2: Type and Severity of Identified Hearing Losses (By Ear)

DSHPSHWA System*

(Note: Please report once using either the DSHPSHWA or ASHA system)

Total Permanent Hearing Loss

(from Part 1 Diagnostic section)

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

Severity

 

 

 

 

 

 

 

 

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

Totals by Child

Total Cases Resolved (i.e., change from hearing loss to no hearing loss)

Overall Total*

(automatically calculated*)

Note*: The “Overall Total” must match the value listed for “Total Permanent Hearing Loss” at the top of this page (and taken from the Part 1 Diagnostics section). If there is any difference you will receive an error message.

Part 2: Type and Severity of Identified Hearing Losses (By Ear)

ASHA System*

(Note: Please report once using either the DSHPSHWA or ASHA system)

Total Permanent Hearing Loss

(from Part 1 Diagnostic section)

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

Slight

 

 

 

 

 

 

 

Mild

Moderate

 

 

 

 

 

 

 

 

Moderately Severe

 

 

 

 

 

 

 

 

Severe

 

 

 

 

 

 

 

 

Profound

Unknown

Severity

 

 

 

 

 

 

 

 

Conductive

Slight

 

 

 

 

 

 

 

 

Mild

Moderate

 

 

 

 

 

 

 

 

Moderately Severe

Severe

 

 

 

 

 

 

 

 

Unknown Severity

 

 

 

 

 

 

 

 

Mixed

Slight

 

 

 

 

 

 

 

 

Mild

Moderate

 

 

 

 

 

 

 

 

Moderately Severe

Severe

 

 

 

 

 

 

 

 

Profound

 

 

 

 

 

 

 

 

Unknown Severity

 

 

 

 

 

 

 

 

Type Unknown

Slight

 

 

 

 

 

 

 

 

Mild

Moderate

 

 

 

 

 

 

 

 

Moderately Severe

 

 

 

 

 

 

 

 

Severe

Profound

 

 

 

 

 

 

 

 

Unknown Severity

 

 

 

 

 

 

 

 

Note*: The “Overall Total” must match the value listed for “Total Permanent Hearing Loss” at the top of this page (and taken from the Part 1 Diagnostics section). If there is any difference you will receive an error message.

Screening Demographics Diagnostics Demographics Intervention Demographics Finalize

Part 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 6 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

American Indian or Alaska Native

Asian

Black or African American (Hispanic)

Black or African American (Ethnicity Unknown)

Native Hawaiian or Other Pacific Islander

White (Hispanic)

White (Not Hispanic)

White (Ethnicity Unknown)

Refused

Unknown

Totals (auto calculated)

Hearing Screening Diagnostic Intervention Type/Severity Demographics Finalize

Dear Respondent:

            

Thank you for completing this survey. Before submitting this data you will need to enter your contact information below. 

• The contact information must be completed before the survey can be submitted or any changes made to the data.

• Once submitted, you will not be able to change any of the data reported in this survey.

• Parts 1 and 2 of this survey can be submitted by using the “Submit Survey” button at the bottom of this page.

• Please do not include any commas with the data you enter (it will stop you from submitting the survey).

Contact Information
Name
E-mail
Confirm E-mail
State/Territory
Comments (2,500 Character Limit)

Submit Survey

 

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