SURVEY ON PEDIATRIC AUDIOLOGY SERVICES:
AUDIOLOGICAL ASSESSMENT AND AMPLIFICATION FITTING
FOR CHILDREN BIRTH-36 MONTHS
Please send completed survey to:
Section I.
General Information
1. Agency or Facility:_______________________________________________________
Contact Person________________________________________________________
Title of Contact Person__________________________________________________
Address:_____________________________________________________________
City________________State_________________Zip__________________
Phone Number, including area code: (____) ___________________________
Fax Number, including area code:
(____)____________________________
Email Address:__________________________________________________
2. Does your facility provide diagnostic audiologic services for infants and
toddlers ages birth to 36 months?
__ Yes: If "yes", please
skip question 3 and proceed to question #4.
__ No: If "no", please complete question 3,
then return to above address.
3. Are you interested in receiving training to provide services to infants? Please
check all that apply.
__ No, I am not interested in receiving training at this
time.
__ Yes, I am interesting in receiving training in the following
areas:
__ Behavioral audiometric assessment
__ Immittance Audiometry
__ Auditory Brainstem Response
__ Otoacoustic Emissions
__ Amplification selection techniques
__ Amplification verification techniques
__ Other, describe_______________________________
4. What percentage of infants born in your community have access to universal
newborn hearing screening?
__ Between 0 and 20%
__ Between 21 and 40%
__ Between 41 and 60%
__ Between 61 and 80%
__ Between 81 and 100%
5. Who refers infants to your facility for audiologic assessment. Check all that
apply.
__ Universal newborn hearing screening program(s)
__ High Risk newborn hearing screening program(s)
__ Primary Care physicians
__ ENT physicians
__ Parents of infant
__ Other audiology facilities
__ Other health-care professionals
__ Other personal contacts (e.g., grandparents, neighbors,
other parents)
6. Identify other services available at your facility. Check all that apply.
__ Medical services by a primary care physician
__ Medical services by an otolaryngologist
__ Inpatient medical services
__ Genetic services
__ Child development specialist
__ Social worker or counseling services
__ Speech and language services
Section II.
Diagnostic audiology services for children birth to 36 months of age.
7. How many infants between birth and 36 months of age has your facility seen for
diagnostic evaluations in the last 12 months? (Do not include medical referrals for otitis
media follow-up. )
_________ Number of children birth to 36 months
8. Please estimate the distribution of ages of children you specified in question #7
by
filling out the following table.
|
In this column, please estimate the number of
infants/children you have seen in the past 12 months in each of the following age
categories. |
Birth to 4 months |
_______________________ |
5 to 7 months |
_______________________ |
8 to 12 months |
_______________________ |
13 to 24 months |
_______________________ |
25-36 months |
_______________________ |
9. Estimate the average age at the initial diagnostic evaluation in your facility.
(Do not include medical referrals for otitis media follow-up). Check one of the
following.
__ <3 months
__ 3 months
__ 6 months
__ 9 months
__ 12 months
__ 18 months
__ > 18 months
10. Identify funding sources used for diagnostic testing. Check all that
apply.
__ Self-pay
__ Private insurance
__ Medicaid
__ State agency
(specify)___________________________________________
__ Private non-profit agency
(specify)__________________________________
__ Part C/Part H
__ Other, please
describe:___________________________________________
__ Other, please
describe:___________________________________________
11. Please indicate the techniques you use in the assessment of hearing
in children birth to 36 months of age by completing the following table.
| Diagnostic Procedure |
Check below if you have the
capability to do this procedure |
Check the appropriate
boxes below if you currently use this procedure in the assessment of children in each of
the following age ranges. |
Check below if you
would like to receive additional training or can provide colleagues training
in using this procedure with children birth-36 months of age |
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0-4 months |
5-7 months |
8-12 months |
13-24 months |
25-36 months |
Would like
training |
Can provide
training |
| Otoscopy |
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| Behavioral |
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Startle response to speech
air conduction (AC) |
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| Startle response to tones (AC) |
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Minimal response level to
speech (AC) |
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Minimal response level to
tones (AC) |
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| Startle response to speech bone conduction
(BC) |
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Startle response to pure
tones (BC) |
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Minimal response level to
speech (BC) |
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| Minimal response level to pure tones (BC) |
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Other, describe
____________________ |
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Other, describe
____________________ |
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| Immittance |
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| 226 Hz tympanometry |
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| Multifrequency tympanometry |
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| Ipsilateral acoustic reflexes |
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| Contralateral acoustic reflexes |
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Other, describe
____________________ |
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| Auditory Brainstem
Response |
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| Click Thresholds AC |
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| Tone burst thresholds AC |
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| High intensity click AC |
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| Click threshold BC |
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Other, describe
_____________________ |
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| Otoacoustic Emissions
(OAEs) |
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| Transient Evoked OAEs |
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| Distortion Product OAEs |
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Other, describe
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Section III:
Confirmation of hearing loss in children birth to 36 months of age.
12. Has your facility confirmed a hearing loss in at least one child between the
ages of 0 and 36 months in the past 12 months?
Yes
No: If "no", do not fill out the rest of
section III, proceed to section IV.
13. How many children between the birth and 36 months of age have been confirmed
with a hearing loss by your facility in the past 12 months?
_________________children birth-36 months
14. Please estimate the distribution of ages of children you specified in question
#13 by filling out the following table.
|
In this column, please estimate the number of
infants/children you have confirmed with a hearing loss in the past 12 months in each of
the following age categories. |
Birth to 4 months |
_______________________ |
5 to 7 months |
_______________________ |
8 to 12 months |
_______________________ |
13 to 24 months |
_______________________ |
25-36 months |
_______________________ |
15. Estimate the average age at which children birth-36 months are confirmed with
hearing loss at your facility. Check one of the following.
__ <3 months
__ 3 months
__ 6 months
__ 9 months
__ 12 months
__ 18 months
__ > 18 months
Section IV:
Protocol for reporting confirmation of hearing loss
16. Identify the reporting protocol following confirmation of hearing loss:
__ Reported to state department of health
__ Reported to state department of education
__ Reported to local child find team
__ Reported to primary care physician
__ Reported to referring source
__ Other, please
describe:_____________________________________________
17. How do you track suspected hearing loss and confirmed hearing loss?
__ A manual tracking system is used (skip question
#18, proceed to #19)
__ A computerized tracking system is used (skip question
#18, proceed to #19)
__ No internal tracking is used outside of the infant’s
medical record
(Please complete question # 18 and then proceed to question #20).
18. If you do not track infants with hearing loss outside of the infant’s
medical record, what would help facilitate the collection of this information? Check all
that apply.
__ statewide "confirmation of hearing loss"
reports
__ a national data base collection form
__ state mandated reporting
__ other:______________________________________
19. If you track information regarding infant’s hearing loss what information
do you include? Check all that apply.
__ results of diagnostic ABR
__ results of behavioral assessment
__ OAE results
__ estimated hearing thresholds (based on results of diagnostic
protocol)
__ configuration of hearing loss
__ degree of hearing loss
__ type of hearing loss
__ family history
__ presence of other high risk factors
20. What information do you give to parents before the referral to early
intervention? Check all that apply.
__ type and degree of hearing loss
__ follow-up recommendations for audiologic assessment
__ progressive hearing loss
__ amplification options
__ funding options for assessment and amplification
__ communication methodology options
__ early intervention program options
__ parent-to-parent organizations
__ organizations of Deaf and hard-of-hearing individuals
21. Where does your center refer children who have been confirmed with hearing loss
to insure that they enroll in an early intervention program?
Check all that apply.
__ School for the Deaf
__ Local school district
__ Department of Health
__ Department of Education
__ Part C (Part H) service coordinator
__ State Early Intervention Coordinator for newborn hearing
systems
__ Child Find
__ Private interventionist
__ Other, describe_________________________________________
Section V:
Fitting of amplification on children birth to 36 months of age
22. Do you offer amplification fitting services for children birth-36 months
of age in your setting?
__ Yes
__ No - If "no", do not complete the rest of
Section V.
23. How many children between birth and 36 months of age has your site fit with
amplification in the past 12 months?
_____________________children birth-36 months
24. Please estimate the distribution of ages of children you specified in question #
by filling out the following table.
|
In this column, please estimate the number of
infants/children you have fit with a hearing aid in the past 12 months in each of the
following age categories. |
Birth to 4 months |
_______________________ |
5 to 7 months |
_______________________ |
8 to 12 months |
_______________________ |
13 to 24 months |
_______________________ |
25-36 months |
_______________________ |
25. Identify the average age of referral for amplification in your facility.
__ <3 months
__ 3 months
__ 6 months
__ 9 months
__ 12 months
__ 18 months
__ > 18 months
26. Identify the average age of initial fitting of amplification in your facility.
__ <3 months
__ 3 months
__ 6 months
__ 9 months
__ 12 months
__ 18 months
__ > 18 months
27. Estimate the time interval between confirmation of hearing loss and fitting of
amplification.
__ less than one month between confirmation and fitting
(If less than one month, skip question #28, proceed to question #29)
__ between one and two months between confirmation and
fitting
__ between two and three months between confirmation and
fitting
__ between four and six months between confirmation and fitting
__ greater than six months between confirmation and fitting
28. If there is more than one month between confirmation of hearing loss and fitting
of amplification, identify the issues that contribute to the time lag between confirmation
and fitting )check all that apply):
__ funding for amplification
__ parent follow-up
__ delayed physician referral
__ incomplete diagnostic information
__ inconclusive diagnostic information
__ complicating health issues
29. Identify funding sources used for hearing aids. Check all that apply.
__ Self-pay
__ Private insurance
__ Medicaid
__ Part C/ Part H
__ State agency
(specify)______________________________________________
__ Private non profit agency (e.g., United Way Agency),
describe_______________
__ Service organization (e.g., Sertoma, Kiwanis),
describe_____________________
__ Other, please
describe______________________________________________
__ Other, please
describe______________________________________________
30. Identify the procedures you use in fitting amplification in children
birth-36 months by
completing the following table.
| Fitting Procedure |
Check below if you have the
capability to do this procedure |
Check the appropriate
boxes below if you currently use this procedure in the assessment of children in each of
the following age ranges. |
Check below if you
would like to receive additional training or can provide colleagues training
in using this procedure with children birth-36 months of age |
|
|
0-4 months |
5-7 months |
8-12 months |
13-24 months |
25-36 months |
Would like
training |
Can provide
training |
Sound Field Testing
using calibrated signals |
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Functional Gain for speech
(aided and unaided) |
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Functional Gain for frequency specific stimuli
(aided and unaided) |
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| Probe Microphone Testing |
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| Coupler Testing using real-ear to coupler
correction |
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| Informal behavioral observation |
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Other, describe:
____________________ |
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Other, describe:
____________________ |
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See Sample Confirmed Hearing Loss Report Form
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