Request for Hearing Screening by Audiologist

**Please note that the cost of a hearing screening is $65.00 per student, billable through the SPS Individualized billing process.

By requesting the below services, the district agrees to the cost of requested services.

Date of Request:
Requesting Staff Name and Position:
Email:	Phone:	Requesting District:
Building Location/Address:
Administrator’s Signature from Requesting District:	Date:

Services Available: OAE (Otoacoustic Emission) Hearing Screening and Pure Tone Hearing Screening

Student Name	Student’s LEA	Student’s DOB	Student’s PA Secure ID	OAE (O) or Pure Tone (P)	LEA Approver Name (SPS Supervisor only)	Date Approved by LEA (SPS Supervisor only)	Date Screening Completed (Audiologist only)

**Please scan and email completed form to Jonathan Walter at walterj@cliu.org.

To be completed by CLIU Administrator/Audiologist:

CLIU Administrator Approval of Services:	Date:
Audiologist’s Signature:	Date Services Completed: