Hearing

English > Initiatives > Healthy Athletes > Healthy_Hearing > Hearing_Forms > Hearing_ER

Today's Date
(dd/mm/yyyy)

Program *

List Healthy Hearing Contacts Below:

Clinical Director's Information:

   Full Name *

   Telephone # *

   E-mail *

Special Olympics Program Contact Information:

   Full Name *

   Telephone # *

   E-mail *

Form Completed By:

   Full Name *

   Telephone# *

   E-mail *

Event & Equipment Information

Event Name

Event Location

Est # of Athletes *

Event Begin Date *
(dd/mm/yyyy)

Event End Date *
(dd/mm/yyyy)

Screening Dates *
(dd/mm/yyyy) - (dd/mm/yyyy)

Avg # of Screeners
(per day)

Equip. Needed By *
(dd/mm/yyyy)

Estimated Number of OAE Ear Tips Needed

(small)
(medium)
(large)

Number of Units Requested

Bio-Logic OAE * GSI 37 Auto Tymp * GSI 17 Audiometer *

GSI Tymstar Maico Audiometers Audioscan Verifit

Voltage Other (if voltage not specified)

Were you able to acquire screening equipment locally?

Number of Units Acquired Locally

OAE Units Tympanometers Audiometer

Ship Equipment As Follows (Recipient will be held responsible for the equipment arriving at the venue)

Recipient's Name *

Address *

City *

State/Province *

Country *

Postal Code *

Telephone # *

Fax # *

E-mail Address *

Please indicate any special needs or steps Special Olympics Headquarters should take to facilitate respective custom processes.

Other Needs (not listed):



Comments / Questions:

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