Form CDC EHDI Hearing S CDC EHDI Hearing S CDC

Early Hearing Detection and Intervention

Hearing Screening and Follow-up Survey

Reinstatement with Change

Suhana Alam

Epidemiologist

4770 Buford Hwy. MS E-88

Atlanta, GA 30341

(404) 498-3031

SAlam1@cdc.gov

Attachment 4B:

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

2015 Documented Hearing Screening Data
Total Occurrent Births
Total Occurrent Births According to Vital Records
Optional: Total Occurrent Births at Military Facilities According to Vital Records (Leave this field blank and enter “None” in the cell below if there are no military hospitals)
Please indicate if Optional question above is None
Optional: Total Occurrent Homebirths
Overall Screening Results (Final / Most Recent)
Total Documented as Screened
Total Pass (most recent / final screen)
Pass Before 1 Month of Age
Total Not Pass (most recent / final screen)
Not Pass Before 1 Month of Age
Screening Results
Missed initial / Refer outpatient
Missed initial / Passed outpatient
Pass initial OR Pass initial & Pass outpatient
Refer initial / straight to diagnostic evaluation (including one-stage programs)
Refer initial / Pass outpatient
Refer initial / Refer outpatient
Refer initial / Missed outpatient
Total Pass	0
Total Not Pass	0
No Documented Hearing Screening*
Total Documented as Not Screened
Infant Died
Non-resident
Unable to be Screened due to Medical Reasons
Parents / Family Declined Services
Infant Transferred and No Documentation of Screening
Infant Adopted
Homebirths
Parents / Family Contacted but Unresponsive
Unable to Contact
Unknown
Other
Total Occurrent Births (automatically calculated)**	0
Notes:
*	This applies to one-stage and two-stage protocol sections.
**	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.

2014 Documented Diagnostic Data
Total Not Pass Screening							0
No Documented Hearing Loss
Total with No Hearing Loss							0
No Hearing Loss Before 3 Months of Age
Documented Permanent Identified (ID) Hearing Loss
Total Hearing Loss							0
Hearing Loss ID Before 3 Months of Age
No Documented Diagnosis / Undetermined
Total with No Diagnosis							0
Audiologic Diagnosis in Process (Awaiting Diagnosis) Requirement: Only infants seen at least one time and have a follow-up appointment scheduled
PCP/ENT did not Refer Infant for Diagnostic Testing
Infant Died
Non-resident
Unable to Receive Diagnostic Testing due to Medical Reasons
Parents / Family Declined Services
Moved Out of Jurisdiction
						Infant Adopted
						Homebirths
Parent / Family Contacted but Unresponsive
Please use this dropdown box to indicate the Unresponsive Definition Used*
Unable to Contact
						Unknown
Other
Total Diagnosed and Not Diagnosed (automatically calculated)**							0

Notes:
*	See the HSFS Explanations document for the definitions
**	The value for ““Total Diagnosed and Not Diagnosed (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.

2014 Documented Intervention Data
Total Cases of Hearing Loss							0
Referrals to Part C Early Intervention (EI)
Documented Referral Status							0
Referred to Part C EI
Not Referred to Part C EI
Unknown
Referred to Part C EI Before Six Months of Age*
Number Eligible for Part C EI*
Total Enrolled in Part C EI
Total Enrolled in Part C EI							0
						Signed IFSP Before 6 Months of Age
						Signed IFSP After 6 Months of Age
					Receiving Part C EI Service
						Total Receiving Part C EI	0
						Intervention Service Received Before 6 Months of Age
						Intervention Service Received After 6 Months of Age
						Intervention Service Received After 6 Months of Age, Due to Family Initially Declining Services*
Monitoring Services
Receiving Only Monitoring Services
Receiving ONLY Intervention Services from Non-Part C EI
Total from Non-Part C EI Services Only							0
						Services Before 6 Months of Age
						Services After 6 Months of Age
No Intervention Services
Total No Services							0
Not Eligible for Part C Services
Infant Died
Non-resident
						Unable to Receive EI due to Medical Reasons
Parents / Family Declined Services
Moved Out of Jurisdiction
						Infant Adopted
						Homebirths
Parent / Family Contacted but Unresponsive
Use this dropdown box to indicate the Unresponsive Definition Used**
Unable to Contact
Unknown
Other
Total Intervention & No Services***							0

Notes:
*	The values for “Referred to Part C EI Before Six Months of Age”, "Number Eligible for Part C EI", and "Intervention Service Received After 6 Months of Age, due to Family Initially Declining Services" are not included in any automatically calculated totals.
**	See the HSFS Explanations document for the definitions
***	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.



Notes:
*	Only cases of hearing loss not reported in the Diagnostic Data section should be reported in the below “Hearing Loss not reported in "Documented Permanent Identified (ID) Hearing Loss” section.
*	Only cases of hearing loss not reported in the Intervention Data section should be reported in the below “Cases of Hearing Loss not included in the Early Intervention (EI)" section.
*	Only cases who did not pass hearing screening, has no confirmed diagnosis, but were enabled in early intervention services should be reported in the below "Cases enrolled in EI without a Confirmed Diagnosis" section.
	Hearing Loss Cases not reported in "Permanent Identified (ID) Hearing Loss” (e.g., cases of late onset hearing loss)
	Cases of Non-permanent, Transient Hearing Loss ID
							Permanent Cases of Hearing Loss ID (e.g., late onset)
	Total Cases of Hearing Loss Not Included in Diagnostic Data							0
	Cases of Hearing Loss not included in the Early Intervention (EI) (e.g., cases of late onset hearing loss)
	Total Cases of Hearing Loss Not Included in Diagnostic Data							0
	Total Enrolled in EI (Part C or non-Part C)
	No Intervention: Monitoring Only
							No Intervention: Unknown
	No Intervention: Other
	Total Cases of Hearing Loss Not Included in Early Intervention							0
	Cases enrolled in EI without a Confirmed Diagnosis
	Total Enrolled in EI (Part C or non-Part C)
	Total Cases Enrolled in EI without Confirmed Diagnosis							0



Note: Please see the Instructions tab for additional instructions on completing this tab. Only report Part 2 data using either the DSHPSHWA or ASHA system – do not use both. If you do not see anything on this tab, please confirm you have selected a Type and Severity System on the Instructions Page and then use the links above to navigate to the appropriate system tab.

Total Permanent Hearing Loss

0

Did your Juristiction use different or custom dB ranges?

No

If custom dB ranges were used please list the categories and ranges on the "ASHA Custom dB Reported" Tab above

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

Auditory Neuropathy

Slight

Mild

Moderate

Moderately Severe

Severe

Profound

Unknown Severity

Totals by Ear

0

0

0

0

0

0

0

0

Totals by Child

0

0

0

0

0

0

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

Overall Total*

0

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).

Note: If your Jurisdiction uses different dB ranges, please select the "Yes" option on the "ASHA System" Tab and list the ranges that are used. If different categories are used to classify hearing loss, please list those categories and their corresponding dB ranges below.

ASHA Categories	Hearing Loss Range (dB HL)	Custom Categories	Custom Ranges (dB HL)
Normal	(-) 10 to 15
Slight	16 to 25
Mild	26 to 40
Moderate	41 to 55
Moderately Severe	56 to 70
Severe	71 to 90
Profound	91+

Part 3: Demographics
Note: Please see the Instructions tab for additional instructions on completing this tab.
		Screening			Diagnostics		Intervention
		Total Occurrent Births	Total Pass	Total Not Pass	Normal Hearing	Hearing Loss	Total Enrolled in Part C EI
Totals (from Part 1)		0	0	0	0	0	0
Sex
Male
Female
Unknown
Totals (automatically calculated)*		0	0	0	0	0	0
Maternal Age
<15 years
15-19 years
20 – 24 years
25-34 years
35 – 50 years
> 50 years
Unknown
Totals (automatically calculated)*		0	0	0	0	0	0
Mothers Education
Less than High School
High School Graduate or GED
Some College or AA/AS degree
College Graduate or above
Unknown
Totals (automatically calculated)*		0	0	0	0	0	0
Maternal Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Totals (automatically calculated)*		0	0	0	0	0	0
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 (automatically calculated)*		0	0	0	0	0	0

Notes:

*	The value for “Totals (automatically calculated)” must match the value listed for “Total ” count at the top of this page. If there is any difference you will receive an error message. Please see the red cells that do not match.
	The red shading indicates an error. Please enter the correct numbers in the yellow field to correct the errors.

Final
Comments:
Please use this section to enter any comments and/or caveats about the reported data (2,500 character limit).
Check for Errors:
Please refer to the list below to check for outstanding errors in the survey. If there are any red fields, please navigate to the appropriate tab and fix the error before submitting.
	Part 1: Screening		No errors		Error: "Total Occurent Births" fields don't match. Please go to Screening tab to resolve the error.
	Part 1: Diagnostic		No errors		Error: "Total Not Pass" fields don't match. Please go to Diagnostic tab to reslove the error.
	Part 1: Intervention		No errors
	Part 2: DSHPSHWA		No errors
	Part 2: ASHA		No errors		Error: "Overall Total" field doesn't match "Total Permanent Hearing Loss" field. Please go to ASHA tab to resolve the error.
	Part 3: Demographics		No errors

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