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
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 |
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Total Occurrent Births |
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Total Occurrent Births According to Vital Records |
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Optional: Number of infants in the NICU >5 days? |
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Optional: Total Occurrent Births at Military Facilities According to Vital Records (enter “none” if there are no military hospitals) |
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Optional: Total Occurrent Births at Military Facilities with Hearing Screening Results Reported to the EHDI Program (enter “none” if there are no military hospitals) |
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Hearing Screening |
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Total Documented as Screened |
(automatically calculated) |
Passed (most recent/final screen) |
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Total Pass |
(automatically calculated) |
Pass Before 1 Month of Age |
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Pass After 1 month but Before 3 Months of Age |
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Pass After 3 Months of Age |
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Pass: Age Unknown |
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NICU Infants (>5 days): Pass |
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Not Passed (most recent/final screen) |
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Total Not Pass |
(automatically calculated) |
Not Pass Before 1 Month of Age |
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Not Pass After 1 month but Before 3 Months of Age |
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Not Pass After 3 Months of Age |
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Not Pass: Age Unknown |
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NICU Infants (>5 days): Not Pass |
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Optional: Inpatient (IP) /Outpatient (OP) Screening Protocol Only |
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Not Pass IP screen and did not Receive an OP Screen |
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No Documented Hearing Screening |
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Total Documented as Not Screened |
(automatically calculated) |
Infant Died |
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Non-resident |
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Unable to be Screened due to Medical Reasons |
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Parents / Family Declined Services |
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Infant Transferred and No Documentation of Screening |
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Missed |
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Unknown |
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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 |
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Total Not Pass Screening |
(from Screening section) |
No Documented Hearing Loss |
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Total with No Hearing Loss |
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No Hearing Loss Before 3 Months of Age |
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No Hearing Loss After 3 Months but Before 6 Months of Age |
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No Hearing Loss After 6 Months of Age |
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No Hearing Loss Documented: Age Unknown |
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Documented Permanent Identified (ID) Hearing Loss |
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Total Hearing Loss |
(automatically calculated) |
Hearing Loss ID: Before 3 Months of Age |
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Hearing Loss ID After 3 Months but Before 6 Months of Age |
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Hearing Loss ID After 6 Months of Age |
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Hearing Loss ID: Age Unknown |
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No Documented Diagnosis / Undetermined |
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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 |
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Non-resident |
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Moved Out of Jurisdiction |
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Infant Died |
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Unable to Receive Diagnostic Testing due to Medical Reasons |
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PCP did not Refer Infant for Diagnostic Testing |
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Parents / Family Declined Services |
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Parent / Family Contacted but Unresponsive |
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Unable to Contact |
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Unknown |
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Total Not Pass* |
(automatically calculated) |
Optional: Other Documented Cases of ID Hearing Loss |
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Cases of non-permanent, transient hearing loss ID |
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Permanent cases of hearing loss among infants reported as Non-Residents |
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Permanent cases of hearing loss among infants that are residents but were born in a different jurisdiction |
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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 |
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Total Cases Hearing Loss |
(from Diagnostic section) |
Referrals to Part C Early Intervention (EI) |
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Total Referrals to Part C EI |
(automatically calculated) |
Referred and Eligible for Part C EI |
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Referred and Not Eligible for Part C EI |
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Referred but Eligibility Unknown |
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Not Referred to Part C EI and Unknown |
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Optional: Referred to Part C EI Before Six Months of Age |
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Total Referred, Not Referred, and Unknown |
(automatically calculated) |
Enrolled in Part C EI |
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Total Enrolled in Part C EI |
(automatically calculated) |
Enrolled Before 6 Months of Age |
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Enrolled After 6 Months but Before 12 Months of Age |
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Enrolled After 12 Months of Age |
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Enrolled: Age Unknown |
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Monitoring Services |
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Receiving Only Monitoring Services |
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Receiving ONLY Intervention Services from Non-Part C EI |
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Total from Non-Part C EI Services Only |
(automatically calculated) |
Services Before 6 Months of Age |
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Services After 6 Months but Before 12 Months of Age |
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Services After 12 Months of Age |
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Services: Age unknown |
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No Intervention Services |
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Total No Services |
(automatically calculated) |
Not Eligible for Part C Services |
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Infant Died |
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Parents / Family Declined Services |
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Non-resident |
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Moved Out of Jurisdiction |
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Parent / Family Contacted but Unresponsive |
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Unable to Contact |
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Unknown |
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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) |
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Hearing Loss ID: Before 3 Months of Age |
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Hearing Loss ID After 3 Months but Before 6 Months of Age |
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Hearing Loss ID After 6 Months of Age |
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Hearing Loss ID: Age Unknown |
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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) |
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Total Cases of Hearing Loss (not included above) |
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Total Enrolled in Part C EI |
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Total Services from Non-Part C EI services |
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No Intervention: Monitoring Only |
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No Intervention: Unknown |
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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)
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Calculate Totals (yellow fields)
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BILATERAL |
UNILATERAL |
LATERALITY UNKNOWN (for Cases where it is unknown if the loss is unilateral or bilateral) |
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RIGHT EAR |
LEFT EAR |
UNKNOWN EAR (Note: record degree of loss for each ear) |
RIGHT EAR |
LEFT EAR |
UNKNOWN EAR |
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Sensorineural |
Mild |
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Moderate |
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Severe |
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Profound |
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Unknown Severity |
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Conductive |
Mild |
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Moderate |
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Severe |
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Unknown Severity |
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Mixed |
Mild |
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Moderate |
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Severe |
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Profound |
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Unknown Severity |
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Type Unknown |
Mild |
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Moderate |
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Severe |
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Profound |
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Unknown Severity |
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Auditory Neuropathy |
Mild |
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Moderate |
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Severe |
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Profound |
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Unknown Severity |
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Totals by Ear |
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Totals by Child |
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Total Cases Resolved (i.e., change from hearing loss to no hearing loss) |
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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)
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Calculate Totals (yellow fields)
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BILATERAL |
UNILATERAL |
LATERALITY UNKNOWN (for Cases where it is unknown if the loss is unilateral or bilateral) |
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RIGHT EAR |
LEFT EAR |
UNKNOWN EAR (Note: record degree of loss for each ear) |
RIGHT EAR |
LEFT EAR |
UNKNOWN EAR |
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Sensorineural |
Slight |
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Mild |
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Moderate |
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Moderately Severe |
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Severe |
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Profound |
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Unknown Severity |
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Conductive |
Slight |
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Mild |
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Moderate |
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Moderately Severe |
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Severe |
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Unknown Severity |
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Mixed |
Slight |
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Mild |
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Moderate |
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Moderately Severe |
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Severe |
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Profound |
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Unknown Severity |
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Type Unknown |
Slight |
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Mild |
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Moderate |
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Moderately Severe |
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Severe |
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Profound |
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Unknown Severity |
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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
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Screening |
Diagnostics |
Intervention |
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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) |
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Sex |
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Male |
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Female |
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Unknown |
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Totals (auto calculated) |
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Maternal Age |
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<15 years |
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15-19 years |
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20 – 24 years |
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25-34 years |
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35 – 50 years |
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> 50 years |
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Unknown |
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Totals (auto calculated) |
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Mothers Education |
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Less than High School |
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High School Graduate or GED |
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Some College or AA/AS degree |
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College Graduate or above |
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Unknown |
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Totals (auto calculated) |
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Maternal Ethnicity |
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Hispanic or Latino |
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Not Hispanic or Latino |
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Unknown |
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Totals (auto calculated) |
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Maternal Race |
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American Indian or Alaska Native |
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Asian |
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Black or African American (Hispanic) |
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Black or African American (Ethnicity Unknown) |
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Native Hawaiian or Other Pacific Islander |
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White (Hispanic) |
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White (Not Hispanic) |
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White (Ethnicity Unknown) |
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Refused |
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Unknown |
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Totals (auto calculated) |
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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 |
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Name |
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Confirm E-mail |
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State/Territory |
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Comments (2,500 Character Limit) |
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Submit Survey
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Marc |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |