EHPI-PALS Facility Survey

Attachment 4 – Revised Survey Form Approved

OMB NO. 0920-0955

Exp. Date: xx/xx/xxxx

Note: The 2 new questions we proposed to add are highlighted on page 7

Section 1. EHDI-PALS Early Hearing Detection & Intervention Links to Services

This directory ONLY captures facilities where licensed audiologists are providing diagnostic assessment and/or device services (e.g. hearing aids, cochlear implants, baha, earmolds) to children age 0 to 5 years. Please check these boxes in order to indicate that your facility (2) includes licensed audiologists AND (b) provides diagnostic assessment or hearing aid services to children five years of age or younger.

Participation in the EHDI-PALS facility survey is voluntary. You can choose to stop at any time and return later to complete the survey. Should you wish to have your facility removed from the EHDI-PALS directory, simply email [email protected] with your name and contact information. A verification email will be sent to the point of contact for your facility prior to its removal.

Please note the starred (*) items require a response.

*Does this facility you are completing the survey for provide services to children under the age of 5?

Yes <next question>

No <if no, display this message: “Thank you for your interest. This directory captures facilities where licensed audiologists are providing diagnostic assessment and hearing aid services to children age 0 to 5” and exit survey>

*In your facility, do the audiologists who provide services to children hold current and appropriate state licenses?

Yes <next question>

No <if no, “Thank you for your interest. This directory captures facilities where licensed audiologists are providing diagnostic assessment and hearing aid services to children age 0 to 5”>

Public reporting burden of this collection of information is estimated to average 9 minutes, 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 response 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: PRA (0920-0955)

Section 2- Your Contact Information

Your contact information is particularly important so we can send you updates about EHDI-PALS and renewal information for your facility's account. Please enter YOUR contact information.

*Your name:

Your position in the facility:

*Your e-mail address:

*Your phone number, including area code (xxx-xxx-xxxx): (for internal use only)

Section 3- Facility Information (information in this section will be displayed publicly)

Please provide contact information for the location where pediatric audiology services are provided. Please enter information for your facility.

*Name of facility

Type of facility: (please check all that apply)

Hospital audiology clinic

Medical office (e.g. ENT office)

Private practice

University audiology clinic

Public school audiology (where client base is geographically restricted to school district)

Nonprofit center

Military

Indian Health Service clinic

State affiliated clinic/hospital

Other: <free-text field>

*Contact person for your facility <allow a check box ‘same as above’ if the person completing the survey is the same. This is the person at your facility who patients should contact. If there is not a specific person, please write “None”

Email address of the above contact person for your facility or an e-mail address for patient to schedule an appointment: <allow a check box ‘same as above’ if the person completing the survey is the same>

Facility’s website address:

E-mail address of facility (e.g. [email protected]):

*Facility telephone (voice), including area code (xxx-xxx-xxxx):

Section 4- Reporting to other agency

Your answer to the following question will not impact your inclusion in the EHDI-PALS facility directory

*Does your facility perform diagnostic hearing test

Yes

No <If clicked go to section 5>

*Does your facility typically report or refer hearing screening result and or diagnosed permanent hearing loss to: (please choose all that apply)

My state/territory newborn hearing screening (EHDI) program yes, no

An Early Intervention program (Part C) yes, no

My local school district (Part B) yes, no

*How often do you typically report findings to your state/territory newborn hearing screening (EHDI) program?

We report more than 2/3 of cases

We report less than 2/3 of cases

*Which of the following best describes the type of cases you typically report (choose all that apply)

Transient conductive hearing loss

Normal hearing findings

Suspected normal hearing

Confirmed permanent hearing loss

Suspected hearing loss

Incomplete test result

Hearing screening results

Hearing aid fitting and/or cochlear implantation

*Do you send updates when there is a change in hearing (resolved, improved, worsened or change in the type of hearing loss)?

Yes

No

*If your facility provides audiologic service to an out-of-state child, do you typically report results to other state’s newborn hearing screening (EHDI) program?

Yes

No

*Do you know the risk factors for late-onset hearing loss in children described by the Joint Committee on Infant Hearing (JCIH)?

Yes <If yes go to next question>

No <If no, go to section 5>

Section 5- Audiologic Evaluation

Please identify all the services your facility provides to children from birth to age 5:

*We provide diagnostic Auditory Brainstem Response (ABR) evaluations using: (Select all that apply)

Click Yes No

Frequency specific tone burst/tone pip Yes No

Bone conduction Yes No

Diagnostic equipment for the purpose of screening Yes No

We provide Auditory Steady-State Response (ASSR)

Yes

No

Service not provided

*Immittance measures:

Tympanometry with a 226 Hz probe tone Yes No

Tympanometry with a high frequency probe tone Yes No

Acoustic Reflex measurements Yes No

*Otoacoustic Emissions (OAE):

Distortion Product OAE Yes No

Transient Evoked OAE Yes No

*Behavioral Audiologic Assessment:

Visual Reinforcement Audiometry (soundfield non ear specific) Yes No

Visual Reinforcement Audiometry (ear and frequency specific) Yes No

Conditioned play audiometry Yes No

Conventional audiometry Yes No

Section 6- Case Load

Your answer to the following questions will not impact your inclusion in the EHDI-PALS facility listing

*Please estimate how many diagnostic evaluations in each of the following age groups have been completed in your facility over the past year?

0-30 days of age

1- 3 months of age

4-24 months of age

25 – 60 months of age

<Dropdown for each age range with following choices: Zero, 1-10, 11-25, 26- 50, More than 50>

*Please estimate how many children were confirmed with permanent hearing loss at the following ages in the past year?

0-30 days of age

1- 3 months of age

4-24 months of age

25 – 60 months of age

<Dropdown for each age range with following choices: Zero, 1-10, 11-25, 26- 50, More than 50>

Section 7- Hearing Aids

*Does your facility dispense hearing aids?

Yes

No

*Does your facility program or service hearing aid purchased elsewhere?

Yes

No

(if no & no skip to section 9>

*Hearing aids are dispensed or serviced for what age groups? (Select all that apply)

Birth to 6 months

>6 months to <3 years

3 years to 5 years

Older than 5 years

*Does your facility typically perform real ear measurements (RECD) to verify hearing aid settings?

Yes

No

*For real-ear measures, do you (Select all that apply)

Measure the individual ear?

Use age-normed average coupler values?

Use default values provided in manufacturer’s software?

None of the above

*For verification, do you use (Select all that apply)

Manufacturer’s proprietary fitting formula

Evidence-based formulae (e.g., DSL, NAL)

Other (please describe) <free text>

None of the above

*When are hearing aids verified? (Select all that apply)

During first visit or at 1^st fit

During monitoring visits

With new earmold fittings

When concerns arise

None of the above

*Does your facility typically perform aided speech perception testing in soundfield or administer parent questionnaire to validate results?

Yes

No

Please estimate how many children with hearing aids are being followed by your facility in the past year? Please also include cases where you are not the dispensing audiologist.

Birth to 6 months

>6 months to <3 years

3 years to 5 years

<Dropdown for each age range with following choices: Zero, 1-10, 11-25, 26- 50, More than 50>

Please estimate how many children were dispensed with hearing aids in your facility over the past year?

Birth to 6 months

>6 months to <3 years

3 years to 5 years

<Dropdown for each age range with following choices: Zero, 1-10, 11-25, 26- 50, More than 50>

Section 9- Other Hearing Aid Services

*Does your facility have access to loaner hearing aids?

Yes

No

Does your facility work through charitable organizations to obtain funding for hearing aids?

Yes

No

Do you take ear impression to dispense earmold for the following age groups?

	Yes	No
Birth to 3 years
>3 to 5 years

Are FM systems dispensed to infants and/or young children in the following age groups?

	Yes	No
Birth to 3 years
>3 to 5 years

Section 10- Cochlear Implant & Vestibular Services

Does your facility provide pediatric vestibular assessments?

Rotary Chair Yes No

VEMP Yes No

VNG Yes No

Vestibular rehabilitation Yes No

*Does your facility provide any of the following cochlear implant services?

Candidacy evaluation Yes No

Surgery Yes No

Initial Mapping Yes No

Subsequent Mapping or Follow-up/monitoring Yes No

Re/habilitation services Yes No

*Does your facility include other providers (such as speech language pathologists, social worker or psychologist etc.) during the pre-implant evaluation?

Yes

No

Please estimate how many children in the 0-5 year age range with cochlear implants are currently managed in your facility.

Zero

1-10

11-25

26- 50

51-99

More than 100

Section 11- Telepractice Capability

Does your facility provide any services via telepractice?  

Yes

No <if clicked proceed to next section: 12>

What type of service is available through telepractice? (Select all that apply).

ABR testing

OAE testing

Immittance testing

Behavioral testing

Hearing aid programming

Cochlear Implant programming

Intervention/therapy/rehabilitation

<If any choices from ABR to cochlear implant and Intervention are chosen, must answer questions A and B>

<If any choices from ABR to cochlear implant is chosen, but not intervention, answer question A only>

If only Intervention/therapy/rehabilitation is chosen, answer question B only

Where the specialist is located

1. Please check all the telepractice set up for testing and device programming currently in your facility:

Where the patient is located and sees specialist via internet connection

I am the host site

I am the spoke site

My host or spoke site partners are: (please enter the facility name) ____________________

2. Please check mark the telepractice set up for intervention/ therapy/ rehabilitation service currently in your facility: (select all that apply

Where the specialist is located

Where the patient is located and sees specialist via internet connection

I am the host site

I am the spoke site

Spoke site has the requisite therapy materials. Patient comes to the spoke site and host remote in to provide the service

Spoke site personnel trained to do the therapy. Patient comes to the spoke site while host remote in to collaborate and supervise

Materials are sent to patient ahead of time and host remote in to patient’s home to provide the therapy

My host or spoke site partners are: (please enter the facility name) ______________________

*Please indicate which of the following services are available through this facility either onsite, in the same campus facility or in the same care system? (Change No to Yes as applicable)

	Yes	No
Primary care provider
Genetics
Pediatric Ophthalmology
Pediatric Neurology
Developmental Pediatrician
Endocrinologist
Pediatric ENT/Otolaryngology
Cleft palate team
Cranio-facial team
CI candidacy evaluation team
Speech Language Pathologists
Early Intervention specialist
Social work/ Psychologists
Occupational Therapists
Physical Therapists
Family to Family Support

Do you offer other languages such as:

	On-site translator	Interpreter available upon advance request	Written materials are available in this language	Telephone interpreter service
Spanish
Chinese (Mandarin)
Korean
Russian
Tagalog
Vietnamese
Other: (please list)

*Which of the following best describes American Sign Language (ASL) service availability at your facility:

Bilingual audiologist fluent in ASL on-site

On site ASL interpreter available

ASL interpreter available upon request

Cannot provide ASL interpreter service

Is your facility wheelchair accessible?

Yes

No

Your answer to the following questions will not impact your inclusion in the EHDI-PALS facility listing

*Typical wait time for an appointment:

Infant diagnostic

Behavioral testing

Hearing Aid evaluation

Cochlear Implant candidacy

Choices for each of the above- less than 1 week, 1-2 weeks, 3-4 weeks, 5-8 weeks, greater than 8 weeks

In addition to the first available appointment, the healthcare industry often likes to measure average wait time by looking at the third available appointment. How long is the typical wait time for patients to access the third available appointment?

Infant diagnostic

Behavioral testing

Hearing Aid evaluation

Cochlear Implant candidacy

Choices for each of the above- less than 1 week, 1-2 weeks, 3-4 weeks, 5-8 weeks, greater than 8 weeks

Do you have weeknight and or weekend hours?

Yes

No <skip to section X>

Section X- Hours and Scheduling

Please indicate for the following services:

Infant diagnostic

Behavioral testing

Hearing aid evaluation

Cochlear implant candidacy evaluation

Choices for each of the above- Mon night, Tue night, Wed night, Thu night, Fri night, Sat, Sun

Section 16- Insurance

*Please list the payment options available for each of the following services (please check all that apply):

	Medicaid	Health insurance	Credit Cards	Payment Plans	Sliding Fee Scale	Other	Part C	Tricare
Audiologic assessment
Hearing aid assessment
Hearing aids fitting
Earmolds
CI surgery & candidacy evaluation
CI programming / re-programming
Auditory training for CI recipients

Note: "Health insurance" includes Blue Cross, Kaiser Permanente. "Other" includes Indian Health Services, free, state funding etc.

*Is there an audiologist in your facility that is an approved provider for your state’s birth to 3 intervention program?

Yes

No or not applicable

*Is there an audiologist in your facility that is an approved provider for your state’s Title V (Children with Special Health Care Needs) program?

Yes

No or not applicable

Following message will be displayed after the last question has been answered:

Thank you for completing your EHDI-PALS profile.

 

I hereby confirm that the information provided is verifiable and accurate to the best of my knowledge. I understand that this information will be made public on the EHDI-PALS website. The target audience will include consumers/families, healthcare providers, and Early Hearing Detection and Intervention program stakeholders. Click the following to confirm your profile:

I affirm the accuracy of the current information provided.

 

Button:

 

You can log back into your account and update your facility profile at any time. In addition, we will send you an annual e-mail reminder to review and then re-confirm or update your information.  It will therefore be important to keep the contact e-mail in your profile up-to-date.