2025 School Hearing Screening Consent and Results form

School Screening Information and Consent

Child's Details

School *

Start typing your school name to restrict the list of schools to select from. Please note there are many schools with similar names, check you have selected the correct school.

First name *Child's first name

Last name *Child's last name

Full name of student *

Year level *

Class *

Please upload any relevant files such as rescreen pdfs

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School address

Funded by

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Date of birth *

Gender *

MaleFemaleIndeterminate / intersex / unspecified

Parent / guardian full name *

Email *

Please re-enter email *

Mobile

Home phone

Home address (no. & street) *

Suburb *

State *

Postcode *

Was your child born in Australia? *

YesNo

Does your child identify as Aboriginal or Torres Strait Islander? *

YesNo

Do you speak English at home? *

YesNo

If no, which language do you speak? *

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Hearing Screening

Do you have any concerns about your child's hearing? *

YesNo

If yes, please provide details of concerns with child's hearing *

Has your child had a history of ear infections? *

YesNo

Has your child had any ear surgery or seen an Ear, Nose and Throat Specialist? *

YesNo

If yes, please provide details of surgery or ENT findings *

Has your child's hearing been tested before (other than newborn screening)? *

YesNo

If yes, was a hearing loss diagnosed? *

Does your child have any conditions that may affect this testing? *

YesNo

If yes, please provide details of conditions that may affect testing *

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Consents

Do you give permission for Hear and Say to share your child's results with the school? *

YesNo

Do you give permission for Hear and Say's research team to contact you in the future about potential research projects? This does not mean you agree to take part in any future research. *

YesNo

Do you agree for Hear and Say and/or its partners to take photographs/video footage of your child during services and activities organised or provided by Hear and Say? You understand these photos or videos may be used by Hear and Say and its partners for media, print and online marketing materials, including but not limited to, social media, training purposes, reporting and funding applications? *

YesNo

By signing below, you agree to and fully understand the following conditions:

I hereby grant Hear and Say permission to provide audiological screening assessment/s to my child as part of the Hear and Say School Hearing Screening Program.
I understand that this program provides a screening assessment and any report given to my child does not constitute a hearing diagnosis. It is a recommendation to obtain further medical assessment.
I understand that it is the parent/guardian’s responsibility to follow up on recommendations for referral.
I understand Hear and Say may contact me following the screening/s if the results indicate a refer result or my child is absent on the day of screening.

By signing below, you agree to and fully understand the following conditions:

I hereby grant Hear and Say permission to provide audiological screening assessment/s to my child as part of the Hear and Say School Hearing Screening Program.
I understand that Hear and Say will share my child's results with the school.
I understand that this program provides a screening assessment and any report given to my child does not constitute a hearing diagnosis. It is a recommendation to obtain further medical assessment.
I understand that it is the parent/guardian’s responsibility to follow up on recommendations for referral.
I understand Hear and Say may contact me following the screening/s if the results indicate a refer result or my child is absent on the day of screening.

Privacy Statement: We collect personal information to enable us to carry out our work in providing screening health services tothe community. Please view the Hear and Say Privacy Policy and Statement at hearandsay.org.au/privacy-policy/.

I acknowledge I have read the Privacy Policy *

Parent / guardian consent

Full name *

Signature *

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Date *

If you are a school representative 'signing' on behalf of the parent please attach the paper Consent Form signed by the child's parent

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OFFICE USE ONLY

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Screening Results

Date of hearing screening

Screening year *

Consent to photograph is NOT given.

Consent to share with school is NOT given.

Student has pass results

Student was absent today

Otoscopy

This is a visual check of the ear canal and ear drum.

Tympanometry

This is a test to determine the health status of the middle ear.

Otoscopy left ear

Tympanometry left ear

Otoscopy right ear

Tympanometry right ear

Otoscopy internal comments

Tympanometry internal comments

Hearing Screening

This is a screen across the major speech frequencies: 0.5 - 4kHz.

Left

WNLHL

Right

WNLHL

L 500

L 1000

L 2000

L 4000

R 500

R 1000

R 2000

R 4000

Hearing screening left ear

Hearing screening right ear

Hearing screening left ear internal comments

Hearing screening right ear internal comments

Overall recommendation

Additional comments

Summary of recommendations

Individual class results

Screener's internal comments

Full name of student1

Invite to Re-Screen Clinic

Student screening complete *

YesPartially completeNot started

This message is appearing because it is expected that one or more of the following fields would have been completed but haven't been:

1. Student screening complete

2. First check completed by

Please click Submit to submit the form to Hear and Say.

Thank you for taking the time to complete this form. We will email your child's results to you after hearing screening has been completed at their school.

2nd check complete, send email to family

YesNo

This message is displayed because one or more of the following fields need to be completed before the child's report is sent to the family:

1. Student screening complete

2. First check completed by

3. 2nd check complete, send email to family

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