MINISTRY OF PRIMARY AND SECONDARY EDUCATION

HEARING AND EAR HEALTH SCREENING TOOL

LEARNER’S SCREENING RECORD

Surname --------------------------------------------------------------------------------------------------------

First Name -----------------------------------------------------------------------------------------------------

Sex ---------------------------------------------------------------------------------------------------------------

Birth Certificate Number --------------------------------------------------------------------------------

If the learner has a Birth Certificate number, then the information on Birth
Certificate number will be input and if they are none then the space will be left
blank

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Learner Welfare, Psychological Services and Special Needs Education Department

LEARNER’S HEARING AND EAR HEALTH RECORD

Province----------------------------------------------------------------------------------------------------------

District------------------------------------------------------------------------------------------------------------

Name of School---------------------------------------------------------EMIS Number--------------------

Name of Learner-----------------------------------------------------------------------------------------------

Date of birth--------------------------------------------------------------Age----------------------------------

Grade----------------------------------------------------Sex----------------------------------------------------

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THE INFORMATION BELOW SHOULD BE COLLECTED FROM PARENTS OR
GUARDIANS THROUGH INTERVIEW AND OBSERVATION

Observable behaviour

Does the child respond when there is communication with him/her?------------------------

Rarely
Sometimes
Always
Never
No answer
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How often does the child use their hands, body movements when communicating?
Rarely
Sometimes
Always
Never
No answer
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Does the child turn to look at the source of sound? Yes/no-------- ---------------------------------------
------------------------------------------

Does the child follow communication with eyes?--------yes/no---------------------------------------------

--------

How often does the child use Sign Language to communicate?------------------------------------------

Rarely
Sometimes
Always
Never
No answer

How often does the child look at the speaker’s face to understand what is being said?
Always
Sometimes
Rarely
Never
No answer

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 -----------------------------------------------------------------------------------------------------------------------------
Does the child react to spoken language without seeing the speaker? Yes/No

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When trying to get another person’s attention, how often does the child do the following:
Waving at the person---------------------------------------------------------------------------------------
Always
Sometimes
Rarely
Never
No answer

 Touching the person-------------------------------------------------------------------------------------------

Always
Sometimes
Rarely
Never
No answer

 Emotional related sign----------------------------------------------------------------------------------------

Always
Sometimes
Rarely
Never
No answer

Observations; as an example – child would not be able to wave as they have no hands(limbs)

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Observable hearing behaviours in natural settings and in class

Item Indicator Always Sometimes Rarely Never

1. The Learner:

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 Requests speaker to
repeat statements in his
or her own language.
2. Tilts better ear towards
the speaker.
3. Has running ear (Pus)

4. Has difficulties in
carrying out oral
instructions
5. Concentrates on
speaker’s mouth for
visual cues.
6. Speaks extraordinarily
soft
7. Speaks extraordinarily
loud
8. Gives inappropriate
responses to questions
(as if answering a
different question)
9. Is slow to take/respond
to instructions?
10. Turns around to face
speaker in a
conversation.
11. Has a voice that seems
not to go up or down
(monotonous)
12. Participation in class is
low
Discussion in class is
low
13. Prefers loud sounds

14. Prefers soft sounds

15. Makes inaudible speech

sounds
16. Has difficulty
understanding speech

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 when there is
background noise
17. Frequently asks others
to speak more slowly
18. Reluctant to continue
with conversation
19. Avoids some social
settings
20. Good at narrating
stories
21. Quick to grasp and
follow instructions
22. Gives accurate
responses to questions.
23. Participates effectively
in conversations
24. Eloquent in speech

25. Enjoys socializing with

other peers

Date of screening--------------------------------------------------------------------------------------------

Screened by (Full Name) ----------------------------------------------Designation ----------------

EC number/ National ID-------------------------------------------------Signature------------------

Supervised by----------------------------------------------------Designation ---------------------------

EC Number/ National ID--------------------------------------------------Signature--------------------