Forms and Material for Clinical Directors
For instructions on how to conduct a screening, download the “Special Olympics Healthy Hearing Guidelines for Standardized Screening Procedures” manual (100 pages, updated July 2006, Adobe PDF, 2M). This manual was authored by:
- Gilbert R. Herer, Ph.D., CCC-A
Global Clinical Director, Healthy Hearing
gherer@cnmc.org
- Judy K. Montgomery, Ph.D., CCC-SLP
Global Clinical Coordinator, Healthy Hearing
montgome@chapman.edu
To volunteer to assist in a Healthy Hearing screening or to find more about the Program, please contact Drs. Herer and Montgomery.
The following forms are designed for the use of Clinical Directors when administering their individual programs:
Special Olympics Healthy Hearing Equipment Requests: If you are not able to acquire the necessary hearing screening equipment locally, or require additional units to augment what you have acquired locally, i.e., Bio-Logic otoacoustic emission (OAE) units and Biocoustics, Inc. tympanometers and audiometers, please complete the Healthy Hearing order form. Two versions of the form are available:
Complete either version of the form in its entirety; omitted information will delay fulfillment. Please review the detailed instructions and important additional information available.
STATUS CHECK: To learn the status of your equipment request, review the most recent (14 March 2008) requests/events tracking spreadsheet (Microsoft Excel; 72K).
Screening Summary Results form
The Special Olympics Healthy Hearing Screening Summary Results form (report card) is designed to print two-up on an 8˝" x 11" sheet of paper; cut the paper in half horizontally to create two 8˝" x 5˝" forms for each sheet printed (exception: the Chinese language version fills one sheet.)
Download English version (Adobe PDF, 62K)
Download Translated versions:
- Arabic (Adobe PDF, 168K)
- Bulgarian (Adobe PDF, 195K)
- Chinese (Adobe PDF, 186K)
- Czech (Adobe PDF, 83K)
- Danish (Adobe PDF, 20k)
- Dutch (Adobe PDF, 65K)
- French (Adobe PDF, 84K)
- German (Adobe PDF, 20K)
- Greek (Adobe PDF, 97K)
- Hebrew (Adobe PDF, 194K)
- Italian (Adobe PDF, 60K)
- Japanese (Adobe PDF, 122K)
- Lithuanian (Adobe PDF, 64K)
- Polish (Adobe PDF, 84K)
- Portuguese (Adobe PDF, 21K)
- Romanian (Adobe PDF, 61)
- Russian (Adobe PDF, 114K)
- Slovakian (Adobe PDF, 72K)
- Slovenian (Adobe PDF, 68K)
- Spanish (Adobe PDF, 32K)
- Turkish (Adobe PDF, 91K)
Screening Follow-up Recommendations
Download English version (Adobe PDF, 74K)
Download Translated versions:
- Bulgarian (Adobe PDF, 106K)
- Czech (Adobe PDF, 92K)
- Danish (Adobe PDF, 22K)
- Dutch (Adobe PDF, 74K)
- French (Adobe PDF, 73K)
- German (Adobe PDF, 21K)
- Greek (Adobe PDF, 98K)
- Italian (Adobe PDF, 63K)
- Lithuanian (Adobe PDF, 91K)
- Polish (Adobe PDF, 96K)
- Portuguese (Adobe PDF, 22K)
- Romanian (Adobe PDF, 72K)
- Russian (Adobe PDF, 114K)
- Slovakian (Adobe PDF, 103K)
- Slovenian (Adobe PDF, 73k)
- Spanish (Adobe PDF, 74K)
- Turkish (Adobe PDF, 122K)
Pure Tone Threshold Test Results/Recommendations
Download English version (Adobe PDF, 78K)
Download Translated versions:
- Czech (Adobe PDF, 97K)
- Danish (Adobe PDF, 26K)
- Dutch (Adobe PDF, 78K)
- French (Adobe PDF, 78K)
- German (Adobe PDF, 25K)
- Greek (Adobe PDF, 113K)
- Italian (Adobe PDF, 118K)
- Lithuanian (Adobe PDF, 95K)
- Polish (Adobe PDF, 103K)
- Portuguese (Adobe PDF, 25K)
- Romanian (Adobe PDF, 77K)
- Russian (Adobe PDF, 121K)
- Slovakian (Adobe PDF, 98K)
- Slovenian (Adobe PDF, 92K)
- Spanish (Adobe PDF, 80K)
- Turkish (Adobe PDF, 122K)
For more information on Healthy Hearing, contact David Evangelista, Director, Health Programs, at +1 (202) 824-0314 or devangelista@specialolympics.org.
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