Audiological Assessment - Annual

Audiological Assessment | Annual

Students who have previously been referred and evaluated for audiological services are eligible for annual audiological assessments.

 

Pre-Referral

LEAs may request an annual audiological assessment by following the procedure listed below. It is not necessary that the Individualized Education Program (IEP) team convene for this type of referral.

  • Complete the Annual Request for Audiological Evaluation/Services form (D/M 108A). Please DO NOT complete the Initial Request for Audiological Evaluation/Services form (D/M 108) for annual referrals.
  • Include information that is related to the school of attendance, program placement, and services the student is currently receiving.
  • Include behavior and/or academic successes and challenges.
  • Include information regarding the use and functioning of equipment such as hearing aids and/or FM systems.
  • Include medical information related to the student's hearing.
  • Complete the Assessment Plan form (D/M 66) and obtain the parent/guardian signature.
  • The person making the referral should check the box that corresponds to the type of assessment(s) requested. Most often the "other" box is checked followed by the statement, "Audiological assessment to be completed by SELPA contracted audiologist."
  • The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form D/M 66.
  • LEAs are encouraged to have the assessment plans signed close to the date of their LEA audiology evaluation date and within the required time frame.
  • Complete the Authorization for Use and/or Disclosure of Information form (D/M 63) and obtain the parent/guardian signature. Specify the receiving agency's name as the SELPA/Pacific Hearing Services. The disclosing agency will vary depending on whether it is a physician, medical center, or audiologist.

Referral

Forward the following completed documents to the attention of the Audiology Services Program Specialist at the SELPA.

  • D/M 108A Annual Request for Audiological Evaluation/Services form
  • D/M 66 Assessment Plan form
  • D/M 63 Authorization for Use and/or Disclosure of Information form

 

Timeline for Assessment

The audiological assessment must occur within 60 calendar days from the date the Assessment Plan was received by the LEA. When the signed Assessment Plan is received by the LEA, it should be date stamped.

An Audiology Assessment Calendar is published on an annual basis at the beginning of each school year. The calendar lists the assessment dates and referral due dates for each LEA within the SELPA. The calendar may be found on the SELPA website at

For students who require services outside of the regularly scheduled LEA visit, services may be conducted between the SELPA and the LEA. Arrangements may be made for students to be served at the school site, at a nearby LEA, the Desert/Mountain Children's Center (DMCC) or at the service provider's office, whichever is available and appropriate. Please contact the Audiology Services Program Specialist at the SELPA for assistance.
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For more information, please contact our office at (760) 552-6700