GROWTH SCREENING Page 4 of 4 HEARING SCREENING mandated for grades K, 1, 2, 3, 7, 11 and INDICATE DECIBEL (DB) LEVEL FOR EACH FREQUENCY FAILED annually for ungraded special education Right Ear Left Ear Results Referral Date Grade Signature (Screener) Date Date referral pass fail 250 500 1000 2000 4000 8000 250 500 1000 2000 4000 8000 referred completed ANNUAL Date of notification Date Grade Height Weight BMI BMI% Signature (Screener) to parent/guardian
Page 4 of 4 HEARING SCREENING INDICATE DECIBEL (DB) LEVEL FOR EACH FREQUENCY FAILED mandated for grades K, 1, 2, 3, 7, 11 and annually for ungraded special education Date Grade Right Ear Left Ear Results Referral Signature (Screener) 250 500 1000 2000 4000 8000 250 500 1000 2000 4000 8000 pass fail Date referred Date referral completed GROWTH SCREENING ANNUAL Date Grade Height Weight BMI BMI% Date of notification to parent/guardian Signature (Screener)