KYRENE SCHOOL DISTRICT

 Hearing Impairment Program Services/Referral Form

 

Date____________________________Student___________________________

School____________ Grade_____ Regular Education Teacher_______________

Parent Name______________ Parent Phone_____________________________

Referred by:______________ Position___________________________________

  1. Is this student currently receiving speech/language services?
    2.  

     

  2. Is this student currently receiving special education services?
    3.  

     

  3. Is this student currently being referred for the above services?
    4.  

     

  4. When was the most recent school hearing screening completed?
    5.  

     

  5. Has a hearing evaluation been performed by an audiologist?
    6.  

     

  6. Do health office records indicate a previously diagnosed hearing loss?
    7.  

     

  7. Do health office records indicate chronic otitis media?
    8.  

     

  8. Does this student wear hearing aids?
    9.  

     

  9. Have the parents been notified of this referral?
 

 

Please state the specific reason for this referral:___________________________

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Describe interventions that have been attempted with this child.

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