Illinois Hearing Test Audiogram Form
This form is used by the Illinois Department of Public Health to record the results of an audiogram hearing test. It includes fields for personal information, test environment, thresholds, and referral criteria. This form is critical for ensuring accurate and consistent hearing assessments.
Edit, Download, and Sign the Illinois Hearing Test Audiogram Form
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out this form, start by providing the personal information such as name, birth date, and contact details. Then, record the audiogram test results in the appropriate fields. Ensure to check the minimum criteria for referral and sign the form if necessary.
How to fill out the Illinois Hearing Test Audiogram Form?
1
Start by entering the personal information in the designated fields.
2
Record the audiogram test results including frequencies and decibels.
3
Check the test environment and response reliability options.
4
Review the minimum criteria for referral and check the appropriate boxes.
5
Sign and date the form if a referral is necessary.
Who needs the Illinois Hearing Test Audiogram Form?
1
Schools for recording student hearing test results.
2
Healthcare providers for documenting patient audiogram findings.
3
Audiologists for assessing hearing loss over time.
4
Public health officials for tracking population hearing health.
5
Parents to understand their children's hearing abilities.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the Illinois Hearing Test Audiogram Form along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your Illinois Hearing Test Audiogram Form online.
You can easily edit this PDF on PrintFriendly using our user-friendly PDF editor. Make the necessary changes directly within the document. Save your edits and download the updated PDF.
Add your legally-binding signature.
Signing the PDF on PrintFriendly is simple and straightforward. Use our built-in signature tool to add your signature to the document. Save and download the signed PDF with ease.
Share your form instantly.
Sharing the PDF on PrintFriendly is quick and efficient. Use our sharing options to send the document via email or generate a shareable link. You can also download the file and share it through other platforms.
How do I edit the Illinois Hearing Test Audiogram Form online?
You can easily edit this PDF on PrintFriendly using our user-friendly PDF editor. Make the necessary changes directly within the document. Save your edits and download the updated PDF.
1
Upload the PDF form to PrintFriendly.
2
Use the PDF editor to enter the required information.
3
Make necessary changes directly within the document.
4
Review the edited form to ensure all information is correct.
5
Save and download the updated PDF.
What are the instructions for submitting this form?
Submit the completed form to the Illinois Department of Public Health via email to healthdept@illinois.gov, fax to (217) 555-5555, or mail to Illinois Department of Public Health, 535 W. Jefferson St., Springfield, IL 62761. Ensure all required fields are filled accurately and include the tester's signature if necessary.
What are the important dates for this form in 2024 and 2025?
Key dates for the form include annual hearing test reporting deadlines. Ensure to complete and submit the form prior to the due dates specified by the Illinois Department of Public Health.
What is the purpose of this form?
The Illinois Hearing Test Audiogram Form is designed to document and assess individual hearing capabilities through audiogram testing. It captures vital information including personal details, test environment, and thresholds for different frequencies. By standardizing the reporting of audiogram results, this form helps ensure consistent, accurate, and actionable hearing health assessments.
Tell me about this form and its components and fields line-by-line.
- 1. Personal Information: Includes fields for name, birth date, sex, grade, parent/guardian, phone number, address, and county.
- 2. Testing Details: Fields for testing location, testing agency, tester, audiometer and serial number, and audiogram code.
- 3. Screening Thresholds: Includes threshold levels for various frequencies for both ears.
- 4. Test Environment: Options to indicate whether the test environment was satisfactory or unsatisfactory.
- 5. Responses: Options to indicate whether test responses were reliable or unreliable.
- 6. Referral Criteria: Minimum criteria for referral based on hearing thresholds and frequencies.
- 7. Signature: Field for the tester's signature and date of referral.
What happens if I fail to submit this form?
Failing to submit this form could delay necessary hearing interventions and referrals.
- Delayed Interventions: Without timely submission, necessary medical or educational interventions might be postponed.
- Inaccurate Health Records: Lack of submission may result in incomplete or inaccurate health records for the individual.
How do I know when to use this form?
- 1. School Hearings: For documenting students' hearing test results during school screenings.
- 2. Medical Examinations: Used by healthcare providers during routine audiogram tests.
- 3. Public Health Reporting: To track and report hearing health data within the state.
- 4. Parental Records: For parents to maintain accurate records of their children's hearing health.
- 5. Assessing Hearing Loss: Audiologists use the form for assessing and tracking hearing loss.
Frequently Asked Question
How can I fill out this form?
Use the PDF editor on PrintFriendly to enter the required information in the form fields.
Can I edit the form after filling it out?
Yes, you can edit the form using the PDF editor on PrintFriendly.
How do I sign the form?
Use the built-in signature tool on PrintFriendly to add your signature to the PDF.
Can I share the completed form?
Yes, you can share the form via email or generate a shareable link on PrintFriendly.
What information do I need to fill out the form?
You need personal details, audiogram test results, and responses for test environment and referral criteria.
Do I need to print the form to fill it out?
No, you can fill out and edit the form digitally on PrintFriendly.
How do I save my edited form?
After editing, use the save option on PrintFriendly to download the updated PDF.
Is it possible to check and correct errors on the form?
Yes, review your form on PrintFriendly and make necessary corrections before saving.
Can I use this form for multiple individuals?
No, each form is intended for a single individual's audiogram test results.
Does PrintFriendly offer support for form editing?
Yes, PrintFriendly provides tools and support for editing PDFs.
Related Documents - IL Audiogram Form
Phonak Virto B and CROS B Order Form Details
This file contains the Phonak Virto B and CROS B order form for custom hearing instruments. It provides step-by-step instructions on how to complete the form. The form includes patient information, technology selection, and additional product options.
