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

Early Hearing Detection and Intervention Hearing Screening and Follow-up survey

Attach_4B_HSFS_2013

Early Hearing Detecton and Intervention Hearing Screening and Follow-up survey

OMB: 0920-0733

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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



Shape1


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!

Shape2 ASHA system

Shape3 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 Totalmust 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 Totalmust 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.

Shape4

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)















Shape5

Hearing Screening Diagnostic Intervention Type/Severity Demographics Finalize


Shape6

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)










Text Box 7_0

Submit Survey







 














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