Services For Students Who Are Deaf Or Hard Of Hearing Medical/audiological Evaluation Report

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South Bend Community School Corporation
Special Education Services
215 S. St. Joseph St, South Bend, IN 46601
Ph: 574.283.8130 Fax: 574.283.810
Services for Students who are Deaf or Hard of Hearing
Medical/Audiological Evaluation Report
To the Physician:
The South Bend Community School Corporation provides special education services for students who meet state
law eligibility requirements. These requirements include an educational evaluation and an examination report that
contains a diagnosis and etiology of the hearing loss and a description of any potential requirements for
amplification.
Student: ____________________________________________ DOB:_____________ School:_______________
Otological Examination:
Ears:
Right: Condition of external ear and canal__________________________________________________
Condition of middle ear and drum___________________________________________________
Left:
Condition of external ear and canal__________________________________________________
Condition of middle ear and drum___________________________________________________
Diagnosis and Etiology of Hearing Loss:
1. Conductive loss___________ Sensori-neural loss____________ Mixed________________
2. Is the loss hereditary (genetic)? __________Is the loss acquired? ______________________________
3. Degree or severity of hearing loss?_______________________________________________________
4. During what period did damage to the auditory mechanism occur?______________________________
___________________________________________________________________________________
5. What is the suspected etiology?__________________________________________________________
___________________________________________________________________________________
Describe any potential requirements for amplification:_________________________________________________
___________________________________________________________________________________________
_____________________
____________________________________________________
Date of Examination
Examining Physician
____________________________________________________
Address
____________________________________________________
Phone
Return To:
Educational Audiologist
____________________________________________________
Hearing Resource Center
Date
Monroe Primary Center
312 E. Donmoyer Ave.
South Bend, IN 46614
(574) 231-5831

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