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85

Appendix

Of

Forms

86

Rev July 2010

Your Name

PURDUE UNIVERSITY

DEPARTMENT OF SPEECH, LANGUAGE AND HEARING SCIENCES

AUDIOLOGY PRACTICUM RECORD FORM FOR THE ASHA CERTIFICATE OF

CLINICAL COMPETENCE You must have documentation on file in the department of all of your clinical practicum clock hours.

These cards or forms must be signed by the ASHA-certified persons who supervised your practicum.

Have you met this requirement?

yes _____ no _____

You must have completed a minimum of 75 credit hours of post baccalaureate education in

Audiology culminating in a doctoral degree. Have you met this requirement?

yes _____ no _____

GRADUATE Audiology Hours

You must have completed a minimum of at least 1820 clock hours of supervised clinical practicum at

the graduate level. Have you met this requirement?

yes _____ no _____

What was the exact date on which you completed all of your clinical practicum requirements?

[Month/Day/Year]

What was your Praxis examination score?

What is your exact date of graduation from Purdue? [Month/Day/Year]

Are your log cards attached to this application?

yes _____ no _____

Have you reviewed your final Academic and Clinical KASA and is it accurate?

yes _____ no _____

When you sign below, this means that you have checked this PR form for accuracy in meeting

ASHA’s minimum practicum requirements for certification.

Student Date Graduate Programs Director Date

__________________________________________

Director of Clinical Education in Audiology Date

GRADUATE

Total Audiology Participation Clock

Hours

88

INFANT ABR LETTER

We appreciate your interest in the services provided at the Purdue University Audiology Clinic. Our clinic serves as a training center for graduate students in speech-language pathology and audiology. All diagnostic, consultative and treatment services are provided under the direction of certified, licensed audiologists.

About the Evaluation: For the evaluation of your infant he/she needs to be asleep. The evaluation can take 1 ½ to 2 hours. Suggestions to help baby sleep through the test: keep your baby up late the night before the date of the evaluation, wake him/her up early on the date of the evaluation, avoid a nap, and feed the baby lightly until the appointment time. You can then feed the baby at the Clinic and this will help the baby sleep through the evaluation. If your baby is awake and fussy, we may obtain limited test results and may have to reschedule your appointment or refer him/her for an evaluation under sedation. *If there are other siblings it is recommended that you make arrangements for them or bring another adult along that can look after them in our waiting room as they are not allowed to be in the testing room. Location: Our clinic is located in Lyles-Porter Hall on the campus of Purdue University, 715 Clinic Drive, West Lafayette, IN 47907. This is on the corner of University and Harrison streets. A campus map and driving instructions are enclosed for your convenience. Parking: Parking is available in designated visitor parking spaces in the first floor of the Harrison Street parking garage located next to Lyles-Porter Hall. It is important that you make an immediate right turn when entering the parking garage and proceed around the first floor to the parking spots designated ‘SLHS/PPTRC Clinics Only’. Proceed through the double metal doors and continue down the hallway to the first floor waiting/reception area (Room#1042). Forms: Please complete the enclosed forms and bring them with you to your scheduled appointment. Cancellations/missed appointments: If you are unable to keep your appointment for any reason, please call (765-494-3789/4229) at least 24 hours prior to your appointment time to cancel or reschedule. If you do not call and do not show up for your appointment our limited clinic hours may keep us from being able to offer another appointment time. Fees: Purdue’s Audiology Clinic provides no cost visits to all children under the age of 5. Appointment times are needed for all visits. Fragrance Free Clinic: To better protect the health of all, especially those individuals with allergies, our clinic is a Fragrance Free Clinic. We appreciate your cooperation by wearing no scented items or fragrances during your visit here. Thank you very much for choosing the Purdue University Audiology Clinic to serve your hearing health care needs. Please feel free to ask your audiologist or call the clinic at (765) 494-3789/4229 if you have any questions.

91

PURDUE UNIVERSITY AUDIOLOGY CLINIC

715 Clinic Drive, Lyles-Porter Hall

West Lafayette, IN 47907-2122

(765) 494-3789

(765) 494-0771 (fax)

PEDIATRIC AUDIOLOGIC CASE HISTORY

Primary concern: Hearing ____ Speech ____ Other: ___________ Problem first noticed:

Newborn hearing screening results: Pass ____ Refer ____ Physician:

Parent 1 Name Parent 2 Name Parent 1 Age ___ Parent 2 Age ____

General health: Excellent___Good___Fair___Poor___ Child adopted or in foster care: Yes ____No ____

Please check the appropriate box – Check the “Yes” box if the condition/situation has EVER been present:

Yes No Medical History Yes No Birth mother diagnosed with:

□ □ Pregnancy problems □ □ Herpes virus

□ □ Medications during pregnancy/nursing □ □ Influenza

□ □ Problems with delivery □ □ Cytomegalovirus

□ □ Neonatal Intensive Care Unit (NICU) □ □ Toxoplasmosis

□ □ Premature □ □ Syphilis

□ □ Low birth weight □ □ Rubella

□ □ Allergies Comments/Notes:

□ □ Hospitalizations _________________________________________

□ □ Head trauma _________________________________________

□ □ Loss of consciousness _________________________________________

□ □ Skull fracture _________________________________________

□ □ Meningitis _________________________________________

□ □ Family history of hearing loss _________________________________________

□ □ Other:

Comments/Notes: Yes No Ear History

_________________________________________ □ □ Excessive ear wax

___________________________________ □ □ Earaches

___________________________________ □ □ Ear infections

___________________________________ □ □ Ear medication

___________________________________ □ □ Punctured ear drum

___________________________________ □ □ Physician consult for ears

___________________________________ □ □ Ear surgery/tubes

_________________________________________ □ □ Ringing/buzzing noises

___________________________________ □ □ Other:

___________________________________ Comments/Notes:

92

_________________________________________

_________________________________________

Yes No Other Diagnoses Yes No Developmental/Educational History

□ □ Speech/Language delay □ □ Responds to sounds

□ □ Vision problems Age first words spoken:

□ □ Attention deficit disorder Age 1st sentence spoken:

□ □ Learning disability □ □ Speech understood by others

□ □ Intellectual disability □ □ Recent behavior/major life change

□ □ Autism □ □ Has priority seating in classroom

□ □ Cleft lip/palate □ □ Receiving therapy/services

□ □ Down syndrome □ □ Worn/wears a hearing aid

□ □ Muscular dystrophy □ □ Used/uses FM system

□ □ Cerebral palsy Grade/School:

Comments/Notes: Comments/Notes:

___________________________________ __________________________________________

___________________________________ __________________________________________

___________________________________ __________________________________________

___________________________________ __________________________________________

___________________________________ __________________________________________

___________________________________ __________________________________________

___________________________________ __________________________________________

___________________________________ __________________________________________

___________________________________ __________________________________________

___________________________________ __________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

96

SAMPLE: FULL SUMMARY REPORT

Report of Hearing Evaluation

RE: J. B. Date of Evaluation: 10/01/2002

Address DOB:

Address Clinic#:

History:

J. B. was seen at the Purdue University Audiology Clinic on the above date for a hearing assessment.

Ms. B. has a history of ear infections as a child and had pressure equalization (PE) tubes placed in

her ears twice. She reported difficulty localizing sounds but did not report any difficulty hearing and

understanding speech. Ms. B. also reported that she sometimes has earaches in her right ear. Ms. B.

was previously seen at the clinic on August 30, 2002 and a perforation was visualized in her right

tympanic membrane, which she believes is probably long standing.

Evaluation results:

Visual inspection revealed a clear ear canal and eardrum in the left ear; an eardrum

perforation was visualized in the right ear

Hearing sensitivity was within normal limits in the left ear; the right ear has a mild

conductive hearing loss, primarily for low frequency sounds

Excellent word recognition scores were obtained in each ear (92% correct in the right ear and

100% correct in the left ear)

A normal tympanogram and acoustic reflexes were obtained in the left ear, consistent with

normal middle ear function

A flat tympanogram with large ear canal volume and absent acoustic reflexes were recorded

in the right ear consistent with a perforation of the eardrum

Recommendations:

Ms. B. was counseled regarding the results of the assessment, and consultation with an ear nose

throat (ENT) physician was recommended to discuss options available for repair of the right

tympanic membrane. Ms. Bo. was instructed to keep the right ear canal dry to reduce the likelihood

of infection until she can see an ENT physician. A hearing re-evaluation was also recommended in

one year or sooner if Ms. B. notices a change in the status of her hearing.

Reported by:

______________________________ ______________________

Supervising Audiologist, Au.D., CCC-A Desi Bell, B.S.

Clinical Assistant Professor Student Clinician

97

SAMPLE: LETTER FORMAT REPORT

July 03, 2002

John Smith, M.D.

Address

Address RE: J. B.

Address

Address

DOB:

Clinic #:

Dear Dr. Smith,

J. B. was seen at the Purdue University Audiology Clinic on the above date for an audiologic assessment.

Ms. B has a history of ear infections as a child and had pressure equalization (PE) tubes placed in her ears

twice. She reported difficulty localizing sounds but did not report any difficulty hearing and

understanding speech. Ms. B. also reported that she sometimes has earaches in her right ear. Ms. B. was

previously seen at the clinic on August 30, 2002 and a perforation was visualized in her right tympanic

membrane, which she believes is probably long standing.

The results of our assessment were as follows:

Otoscopy unremarkable in the left ear; tympanic membrane perforation visualized in the right ear

Left ear: Hearing sensitivity within normal limits

Right ear: Mild conductive hearing loss, primarily in the low frequencies

Excellent word recognition scores bilaterally (92% correct in the right ear and 100% correct in

the left ear)

Normal tympanogram and acoustic reflexes in the left ear, consistent with normal middle ear

function

Flat tympanogram with large ear canal volume and absent acoustic reflexes in the right ear,

consistent with a perforated tympanic membrane

Ms. B. was counseled regarding the results of the assessment, and it was recommended that she return to

you for a consultation to discuss options available for repair of the right tympanic membrane. Ms. B. was

instructed to keep the right ear canal dry to reduce the likelihood of infection. A hearing re-evaluation was

also recommended in one year or sooner if Ms. B. notices a change in the status of her hearing.

Please feel free to call if you have any questions or concerns regarding these test results or

recommendations.

Sincerely,

_______________________________ ______________________

Supervising Audiologist, Au.D., CCC-A Henry Hertz, B.S.

Clinical_______ Professor Student Clinician

Cc: J. B.

98

Spring 2000 SAMPLE REPORT

Semester Progress Report

Name: C. F. DOB: 01/01/99

Parents: Fa. and M. F. CA: 4;9

Address: Street Address Clinic #: 99-000

Anytown, IN 40000 Clinicians: Jane Doe

Phone: (000) 000-0000 John Smith

Supervisors: Name of Supervisor

Date: April 20, 2000 Attendance: 11/14

Pertinent Background Information

C., age 4 years 9 months, began attending the M.D. Steer Audiology and Speech

Language Center in September 1999. Currently, he is enrolled in one 90-minute aural

rehabilitation session per week. He attends Fountain-Warren Head Start, where he also receives

speech therapy.

C. is a typically developing child who suffered meningitis at 5 months of age and was

diagnosed with a profound hearing loss at five and a half months of age. Subsequent trials with

amplification did not prove successful and he received a cochlear implant in his right ear in April

1998, at Riley Children's Hospital. Due to ossification of the cochlea, only 11 out of 22

electrodes can be currently used because of the limited and partial insertion of the electrode

array. The implant was activated in June of 1998.

The Nucleus 24 Sprint Processor (#-----) was programmed utilizing the Win DPS

software and the MP 1+2 mode of stimulation on February 22, 2000. Before the mapping

session, C. wore his speech processor on P4 (ACE processing strategy) with volume and

sensitivity settings on 9, 10 respectively. Sound field-testing indicated that thresholds for warble

tones and speech (d13 HL) were in the mild-to- moderate range. This is within the upper end of

the expected range of performance for a cochlear implant recipient and suggests that average

conversational speech will be audible in quiet listening environments. C. has recently had

problems with static electricity, which has erased his main P4 setting on two separate occasions.

Solutions are being discussed with the implant center on how to prevent this problem from

continuing.

In February 2000, the Devault Otologic Research Laboratory performed a series of

auditory perception tests, and administered the Peabody Picture Vocabulary Test- Third Edition

(PPVT-111) and Reynell Language Developmental Scales. Results of a one and a half year

follow-up examination involving the measures indicated above revealed that C. had made

progress in the development of auditory perceptual skills; however, his receptive and expressive

language skills remained significantly delayed relative to his age-matched peers with normal

hearing. Please refer to clinic file for test results.

99

Communication Goals and Therapeutic Plan

Goal #1 Increase comprehension and production of age-appropriate vocabulary and

concepts, including nouns, verbs, attributes, locations, quantities, and question words.

Progress C. was attentive to the clinicians and exhibited an increased

willingness to participate in structured activities. He required multiple

repetitions of items with pointing and identification. C. enjoyed

matching objects to pictures. For example, C. matched zoo animal

objects to corresponding pictures of the animals. During this activity,

C. signed the following words: same, fly, walk, pig, sheep, and

elephant. C. was also successful in categorizing animals that walk,

fly, and swim. After multiple models, C. was quick to place the

animals in the appropriate categories, but frequently looked to his mother

for praise and the signs associated with his action (e.g., "elephant walks").

C. signed only the animal name (e.g., tiger) or the action (e.g. walk),

but did not sign the two-word combinations (e.g., tiger walks).

Goal #2 Increase auditory awareness and identification of the following: a)

environmental sounds and their source; b) discrimination between vowel

sounds; c) words differing by number of syllables; d) frequently occurring

functional words and phrases.

Progress During speech perception tasks, C. identified one, two, and three

syllable words without speechreading with 81 % accuracy (e.g., dog versus

goldfish; however, with speechreading, he identified these words with

100% accuracy. C.’ s mother reported an increased awareness of

environmental sounds at home (e.g., phone ringing).

Goal #3 C. will demonstrate comprehension of early developing and

frequently occurring commands, questions, and comments, including:

who, what, where, which one, and locatives.

Progress C. responds to what, where, and choice questions in familiar or

structured activities. Many models are required prior to each new activity.

For example, while reading the book Dear Zoo, C. responded to

where questions by pointing to the appropriate objects related to the book.

After receiving multiple models by the clinicians, he also responded to

what questions by signing the following words: dog, elephant, and giraffe.

Currently, C. does not exhibit comprehension of many verbs and

locatives without prior models.

Goal #4 Increase production of 1-3 word phrases for a variety of functions,

including the following: requests (e.g., who, what, and where questions,

more, mine, look, help); responses (e.g., yes/no, making a choice,

answering who, what and where questions); comments (e.g., right here,

mommy gone, want one, stop it, no and, labeling (e.g., nouns).

100

Progress C.’s vocal productions primarily consist of consonant + vowel

syllables involving the consonants /n, b, d, m, w, v/ and a variety of

vowels. He also produces prolonged and intonated vowels, repetitions of

/m-m-m/ and other noises associated with play. In addition, C. uses

single signs to label or comment on items in the environment (e.g., more,

two, same, go, train, socks, horse, pig, cow, sheep, dog, red, yellow,

orange. C. often signed while looking at the referent or the listener.

Some were spontaneous and some were used following several models. In

addition, his facial expressions, eye gaze, and gestures/pointing were

highly communicative. During structured vocal play, with visual

feedback, C. has accurately imitated a variety of vowels within single

syllable words. His mother reports increasingly frequent vocalizations and

speech imitations at home.

General Therapeutic Approaches:

Speech and sign were used simultaneously throughout all interactions with C. Slow,

melodic, repetitive models of words and short phrases provided input of spoken and signed

vocabulary and language. All teaching incorporated environmental and visual context, including

objects, pictures, and written words. Sessions consisted of a variety of experiential and structured

activities and many demonstrations of new tasks were provided to support C.’s participation.

Comprehension of targeted vocabulary and phrases was observed during choice, hiding,

matching, and other activities. Spontaneous productions were encouraged and often imitated by

clinicians in a playful manner. Furthermore, specific speech productions of key words and

phrases were simulated through repetitive models, holding referents near the speaker's face to

encourage observations of speech production, and cues for C. to imitate the words. The

Sensametrics visual speech display software was used to provide visual representation of C.

vocalizations and word productions on the computer screen.

All of his spoken productions were responded to with praise and additional repetitions of

the target and appropriate responses to his intended messages. Over the course of the semester,

clinicians provided C.’s family with vocabulary and auditory perception games to work on at

home, along with suggestions for facilitating spoken and signed language development. C.’s

mother participated in several sessions to practice the language stimulation techniques suggested.

Clinical Impressions

C. is an enjoyable, cooperative, and attentive child. He is highly motivated and enjoys structured

as well as experiential activities. C.’s production and comprehension of spoken and signed

language are severely impaired for a child his age. Due to his limited auditory skills,

C.’s predominant mode of learning tends to be visual. Visual attention and reasoning continue to

remain strengths for C.. The development of auditory perception skills utilizing the auditory

information provided by the cochlear implant are most effectively addressed by relating visual

and auditory information. His signed and vocal communication attempts were more limited with

the clinicians than with his mother. Recently, a new ACE program strategy has resulted in an

increase in C.’s participation level possibly due to an increase in auditory perception.

101

C. is highly expressive, and his use of facial expressions, pointing, gestures, and eye gaze also

served to communicate his messages.

C.’s primary needs involve improving meaningful use of auditory information; therefore

intensive input of spoken language is essential for his learning. Further, expansion of C.’s

comprehension of functional words, concepts, questions, and instructions is a priority for further

development of communication skills. Likewise, expansion of C.’s expressive communication

strategies to communicate a variety of messages warrants intensive intervention.

Recommendations

Based on our work with C. and his family this semester, the following recommendations

are made:

1. Continued intensive communication intervention focusing on the goal areas above,

including: increase comprehension and production of vocabulary and concepts, increase auditory

perception and analysis of spoken information, increase comprehension and response to frequent

questions and commands, and increase spoken productions to accomplish a variety of

communicative functions with peers and adults.

2. It is essential that the cochlear implant be operating and worn at all times. Therefore,

frequent checks of the batteries and wires must be conducted several times a day.

3. Provide an intensive educational program with a focus on teaching that will be effective

as well as supportive during individual learning and interactions with peers.

4. Involvement of C.’s family in all aspects of his educational program.

____________________________________ _____________________________

Name Name

Clinician Instructor-Speech-Language Pathology Student Clinician

____________________________________ _____________________________

Name Name

Clinical Instructor-Audiology Student Clinician

102

SAMPLE: GLASS REPORT

Greater Lafayette Area Special Services

Patient Name: Y. C. Date: 09-01-99

Date of birth: 04-10-96 Clinic #: 99-000

Referring Clinician: Jane Doe/ Out of this World Elementary School

Summary:

Y. C., age 3:4, was seen at the Purdue University Audiology Clinic for a hearing assessment. His

father, F. C., reported concern regarding Y.’s speech and language development. Y. has a

vocabulary of 10 - 20 single words. Mr. C. did not report any other significant history.

Evaluation Results:

Y. did not accept headphones and could not be conditioned to play audiometry. Testing was

therefore completed through loudspeakers using visual reinforcement audiometry. Responses

were obtained to tones and speech stimuli at levels consistent with normal hearing in at least one

ear. Tympanometry could not be completed as Y. was fearful. Although these results are limited,

they are consistent with normal hearing sensitivity in at least one ear.

Recommendations:

1. Complete speech and language evaluation to assess Y.’s speech and language

development and provide appropriate recommendations for remediation.

3. Audiologic re-evaluation in 3 - 6 months to obtain test results for each ear.

Recommendations for Clinician:

Follow as necessary

Action taken:

Report sent to GLASS; Mr. and Mrs. C.

Final Report

Name Name


103

SAMPLE: FIRST STEPS ABR REPORT

April 28, 2009

Ellen Jones

First Steps Services

620 Morland Drive

Lafayette, IN 47905 Re: J. S.

address

Lafayette, IN 47909

DOB: 11------2008

Cl #: --------------

Dear Ms. Jones:

J. S., age 5 months (corrected age 2 months), was seen at the Purdue University Audiology Clinic for

a hearing evaluation on the above date. J. was born at 27 weeks gestation with a birth weight of 2 lb.

5 oz. J. remained hospitalized in the Neonatal Intensive Care Unit for 10 weeks during which time he

received a blood transfusion and was on a ventilator. He failed his newborn hearing screening in the

right ear. J. was noted to be very congested at today’s appointment.

J. was evaluated using auditory brainstem response (ABR) testing and high frequency tympanometry

and the following results were obtained:

Clear and repeatable auditory brainstem responses to high and low pitched sounds were

obtained from each ear consistent with a mild hearing loss in both ears

Tympanograms were flat in both ears indicating reduced eardrum mobility and middle ear

fluid

Overall, these test results suggest that the fluid in Ja.’s ears is affecting his hearing. A permanent

hearing loss could not be ruled out based on today’s test results.

Ms. S. was counseled regarding the results of the evaluation and it was recommended that she

consult with Ja.’s physician Dr. James Livermore and ear, nose and throat physician Dr. Thomas

Brennan regarding his congestion and middle ear fluid. Ms. S. was also counseled regarding the

impact this may have on J.’s speech and language development and recommended a hearing re-

assessment after the fluid has been treated to determine his exact hearing levels.

Thank you for referring J. to our Clinic. Please feel free to contact me if you have any questions

regarding this report.

Sincerely,

___________________________ ____________________________

Supervising Audiologist, CCC-A First name Last name

Clinical Associate Professor Student Clinician

Cc: James Livermore, M.D., Thomas Brennan, M.D., B. S.

104

SAMPLE: First Steps VRA Report April 20, 2009

Bettina Beatty

First Steps Service Coordinator

P.O. Box 6449

Lafayette, IN 47903 Re: B. W.

address

address

DOB: 01-----2007

Clinic #: -------------

Dear Ms. Beatty:

B. W., age 2:2, was seen at the Purdue University Audiology Clinic for a hearing evaluation on the above

date. B. was accompanied by his father D. L. and grandmother T. H. They reported that B. had a head

injury at the age of four months and was hospitalized for one week with intracranial and petechial

hemorrhage. B. was in foster care from the age of 4 – 8 months and then in his grandmother’s care from

the age of 8 months to 2 years (January 2009). B. has been identified with a communication delay and

receives speech therapy services. Ms. H. and Mr. L. reported that he says over 50 words and it was noted

the B. imitated and repeated words during the session. Ms. H. also reported concerns regarding B.’s voice

quality – it seems to be excessively nasal. B. has had a history of ear infections, most recently three

episodes between October – December 2008 that were treated with antibiotics.

B. was evaluated via loudspeakers using lighted toys to reinforce his responses. The results obtained

were as follows:

Tympanograms revealed significant negative pressure in the middle ear, consistent with

Responses to sounds were obtained at levels consistent with a mild high frequency hearing loss in

at least the better ear

Overall, these results suggest a hearing loss in at least the better ear; however due to the abnormal

tympanograms, the nature of the hearing loss is not clear yet.

Ms. H. and Mr. L. were counseled regarding these evaluation results and the following recommendations

were made:

Consultation with an ear, nose and throat physician regarding the abnormal tympanograms and

B.’s nasal voice quality. Ms. H. and Mr. L. reported that they are attempting to obtain Medicaid

insurance for B.. I suggested that they follow-up with you to obtain your assistance with this

process.

Hearing re-evaluation after treatment of the middle ear fluid to determine the exact nature of the

hearing loss. Mr. L. will call us to schedule an appointment after they have had the medical

consultation.

Thank you for referring B. to our Clinic. Please feel free to call contact me if you have any questions regarding this

report. I would also appreciate any assistance with follow-up on these recommendations.

Sincerely,

________________________________ ______________________________

Lata Krishnan, Ph.D., CCC-A Henry Hertz, B.S.

Clinical Professor Student Clinician

Cc: Joel Mulder, D.O., Benton County Medicaid Office, D. L.

105

SAMPLE: REPORT TO THE OFFICE OF VOCATIONAL REHABILITATION

November 11, 2002

Caren Hanley

Office of Vocational Rehabilitation

615 North 18th Street, Suite 202

Lafayette, IN 47904 RE: L. S.

Address

Address

DOB:

Clinic #:

Dear Ms. Hanley:

L. S. was seen at the Purdue University Clinic for a hearing re-assessment on November 07, 2002. Ms. S.

reported a longstanding hearing loss, and has utilized completely-in-the-canal (CIC) style hearing aids in

the past. However, she has lost her left hearing aid. Ms. S. is employed at Purdue University, and her

communication needs in her work environment include listening to student’s questions in the classroom,

meetings at work and a significant amount of travel and communication with other professionals.

The results of the assessment were as follows:

Mild sloping to moderate sensorineural hearing loss in both ears

Fair word recognition scores (72% correct) in each ear

Normal tympanograms consistent with normal eardrum mobility

Ms. S. was counseled regarding the results of the assessment and new hearing aids were recommended.

Due to the demands of her work and classroom environment, it was recommended that she obtain two

digital completely-in-the-canal style hearing aids to optimize her hearing ability in a variety of situations.

Ms. S. was referred to you to determine whether she is eligible for financial assistance in obtaining these

hearing aids.

Please feel free to contact us if you have any questions regarding these test results or recommendations.

We look forward to hearing from you.

Sincerely,

___________________________________ ________________________

Supervising Audiologist, M.S., CCC-A Auriel Field, B.S.


Cc: L. S.

NOTE: VR requires specific speech audiometry testing including word identification scores

in quiet as well as in noise (0 signal-to-noise ratio) at 50 dB HL. They also require that you

submit their audiogram form (forms are available in the Clinic).

106

Audiology Clinical Faculty and Students

Names and Titles to be Used

_____________________________

Lata A. Krishnan, Ph.D., CCC-A

Clinical Professor

Refer to as Dr. Krishnan

____________________________

Melissa Newell, AuD, CCC-A

Clinical Assistant Professor

Refer to as Dr. Newell

_____________________________

Jennifer Simpson, AuD, CCC-A

Clinical Professor

Director of Clinical Education in Audiology

Refer to as Dr. Simpson

___________________________

Anne Sommer, AuD, CCC-A

Clinical Instructor

Refer to as Dr. Sommer

__________________________

Shannon Van Hyfte, AuD, CCC-A

Clinical Associate Professor

Director, Audiology Clinic

Refer to as Dr. Van Hyfte

____________________________

Student First name Last name

Student Clinician OR Graduate Student

111

PURDUE UNIVERSITY

AUTHORIZATION FOR USE, DISCLOSURE OR RELEASE OF

PROTECTED HEALTH INFORMATION AND MEDICAL RECORDS

I hereby request and authorize the use, disclosure and/or release by Purdue University SLHS Audiology and Speech-Language

Clinics and its employees, of medical records, including my social security number, or other protected health information as described

below:

Individual's Name: __________________________________________ Date of Birth: ______________________

Address_____________________________________________________________________________________________ (street) (city) (state) (zip)

I.D.#: ________________________________________ Phone #: _____________________________________

Please identify who is to receive the medical records or other medical information:

__________________________________________________________________________________________________ (name) (fax, if available)

__________________________________________________________________________________________________ (street) (city) (state) (zip)

Please describe specifically what medical records or other health information may be used or released: Any and all discussions about

my treatment or payment for healthcare and all information contained in my paper or electronic medical records

If this request is not made by the Patient, what is the reason for this request?

__Interpreter Services__________________________________________________________________

Unless the “No” box is marked, this Authorization extends to such psychiatric, mental health, and drug and alcohol abuse treatment

information, if any, as may be contained in said medical record including information protected by I.C. 16-39-1-9, I.C. 16-39-2-1

through 16-39-4-2 and I.C. 16-41-8-1. This release permits re-disclosure in accordance with 42 C.F.R., Part 2, which is a federal

regulation governing release and use of medical information pertaining to treatment for alcohol or drug abuse. No

Unless the “No” box is marked, the Authorization also extends to information regarding communicable diseases, including human

immunodeficiency virus (HIV), and AIDS related complex (ARC) and acquired immunodeficiency syndrome (AIDS), if contained in

said medical record. No

I understand that upon release and disclosure of the protected medical records and information, the records and information may be

subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

I understand that Purdue University will not deny treatment, payment, enrollment or eligibility for benefits based upon whether I sign

this authorization. I also understand that an authorization may be necessary in order to process any request I have made for a release

of medical records or other medical information. I may inspect or copy any information used or disclosed under this authorization.

I understand that I may revoke this authorization in writing at any time by mailing or delivering a written revocation to SLHS

Audiology and Speech-Language Clinics, Lyles-Porter Hall, 715 Clinic Drive, West Lafayette, IN 47907-2122. The revocation will

be effective upon receipt by the University, except to the extent that the University has taken action in reliance on this authorization. I

further understand that, this authorization will expire as follows: (1) sixty (60) days from the Signature Date for all records except

mental health records, and (2) one hundred eighty (180) days from the Signature Date for mental health records, unless I specify a

different expiration date or event here: _______________________. After the expiration date, this authorization will no longer be

effective, and no further information will be furnished pursuant to it.

I understand that there may be a charge to cover actual costs incurred by Purdue University in preparing and delivering the

information requested in this authorization, in accordance with Indiana statutes and Purdue policies.

Signed __________________________________ Relationship to Patient:___________________________________ Patient or Legal Representative

______________________________________________ Date_______________ Printed name if not Patient

Witness: _______________________________________ Date_______________

A copy of this form was offered and declined

113




(765) 494-3789

(765) 494-0771 (fax)

Hearing Aid Selection Agreement

All prices are for one hearing aid

Style: Color: Other:

Receiver length/Tubing size: (R) (L) Power: (R) (L)

This is to acknowledge my understanding that the total cost of the hearing aids to be ordered is:

$_____________________, with 50% of this total due at the time of the fitting and 50% due at the end of the

trial period. I understand that I will pay the hearing aid selection/fitting fee of $100.00, the cost of the earmold(s)

($60.00 each, if applicable) and 50% of the total cost of the hearing aid(s) at my next appointment for the hearing

aid fitting. I also understand that the cost of the hearing aid(s) is refundable if I choose not to purchase them at the

end of the trial. However, the fees for services (audiological assessment and hearing aid selection/fitting)

and the cost of earmolds are not refundable.

First payment at HA fitting: HA: __________ EM: _________ Fee: $100 Total: _________________

Second payment if satisfied at end of HA trial: ___________________________________________________

___________________________ _______________________________

Audiologist/ Date Patient/Parent/Guardian/ Date

MEDICAL WAIVER (if applicable)

(Medical clearance from a physician required for children under the age of 18)

I have been advised by Purdue University that the Food and Drug Administration has determined that my best

health interest would be served if I had a medical evaluation by a licensed physician (preferably a physician

who specializes in diseases of the ear) before purchasing a hearing aid. As a consenting adult over the age of 18,

I do not wish to have a medical evaluation before purchasing a hearing aid. To the best of my knowledge there

are no conditions that would prevent me from using a hearing aid.

_________________________ ___________________________________ Date Patient signature

Basic Advanced Premium

$1500 $2000 $2500

114

M.D. STEER AUDIOLOGY AND SPEECH-LANGUAGE CLINICS

Purdue University • Lyles-Porter Hall • 715 Clinic Drive • West Lafayette, IN 47907

____________________________________ has requested an appointment for a hearing aid evaluation in our

clinic. We require this written report of a medical examination before that appointment can be made.

Type of hearing loss: Sensorineural Conductive Mixed

Please check one:

______ Medical findings do not prohibit the use of hearing aids if audiological

tests indicate that amplification is likely to be helpful.

______ Medical findings contraindicate the use of an ear mold/hearing aid in:

the right ear the left ear both ears

______ A hearing aid evaluation should not be completed until further medical

treatment has been given.

Comments: ___________________________________________________________________

_____________________________________________________________________________

________________________________M.D

Address ________________________________

________________________________

Date ________________________________

Please return this form to:

Attention: ____________________________________________

Department of Speech, Language and Hearing Sciences

Lyles-Porter Hall, 715 Clinic Drive

Purdue University

West Lafayette, IN 47907

Fax: (765) 494-0771

115




(765) 494-3789

(765) 494-0771 (fax)

Hearing Aid Agreement

Patient Name:____________________________ Date of Birth:__________________________

Make Model Color Serial # Cost

R:

L:

Ear Molds: _____________________________________________________________________ ________________________

Remote (if applicable):___________________________________________________________________________________ _

Battery Size: _______________________________ Fitting Fee: ______________

Warranty Expiration: _________________________ Total: _______________

Receiver Length/Power: (R) (L) Amount Due at Fitting: ________________

Dome Size: (R) (L) Balance Due at End of Trial: _________________

30-Day Trial Period From:____________________________ to _______________________________

I acknowledge that I have received the above hearing aid(s), that I may evaluate the hearing aid(s) for 30 days, and that I

am responsible for them while they are in my possession. During this trial period, I will be scheduled for follow up

appointments to make necessary adjustments to the hearing aid(s). At the end of the trial period, I may decide to purchase

the hearing aid(s) and pay the balance due; or I may return the hearing aid(s) and receive a refund of the 50% paid toward

the cost of the hearing aid(s). The refund will either be credited to my credit card account or mailed to me within 2-4

weeks. The fees for the hearing evaluation and hearing aid fitting are not refundable. I also understand that the

hearing aid(s) are not returnable and payment is non-refundable after purchase at the end of the trial period. I

understand that ingestion of any battery is a health hazard due to the composition of the battery. I can contact the National

Button Battery Hotline at 202-625-3333 for more information if a battery is accidentally ingested.

____________________________________ ___________________________________

Audiologist/Date Patient/Parent/Guardian/Date

Medical Waiver (if applicable)

(Medical clearance from physician required for children under the age of 18)

I have been advised by Purdue University that the Food and Drug Administration has determined that my best health interest would be

served if I had a medical evaluation by a licensed physician (preferably a physician who specializes in diseases of the ear) before

purchasing a hearing aid. As a consenting adult over the age of 18, I do not wish to have a medical evaluation before purchasing a

hearing aid. To the best of my knowledge there are no conditions that would prevent me from using a hearing aid.

___________________________________ ____________________________________

Patient Signature Date

116




(765) 494-3789

(765) 494-0771 (fax)

Assistive Listening Device Purchase Agreement Patient Name: ___________________________________________ Date of Birth: ___________________

ALD Transmitter: ___________________________________ Serial #: ___________________________________________

ALD Receiver: ____________________________________ Serial #: ___________________________________________

Other: ____________________________________________ Serial #: ____________________________________________

Warranty Description: _______________________________________________________________________________________

30 Day Trial Period: From: ____________________________ To: _____________________________

Transmitter Cost: $____________________

Receiver Cost: $____________________

Other: $____________________

ALD Selection/Fitting Fee: $____________________

Total ALD System Cost: $___________________

I acknowledge that I have received the above ALD system, that I may evaluate it for 30 days, and that I am responsible for it while it

is in my possession. I understand that the total cost of the ALD is: $____________. I understand that I will pay the ALD

selection/fitting fee of $100 (if also purchasing a hearing aid, $100 fitting fee is not charged twice) and 50% of the total cost of the

system at the time of the initial fitting. At the end of the trail period, I may decide to purchase the system and pay the balance due; or I

may return the system and receive a refund of the 50% paid initially. The refund will either be credited to my credit card account or

mailed to me within 2-4 weeks. However, the fees for services (audiological assessment and ALD selection/fitting) are not

refundable. I also understand that the system is not returnable and payment is non refundable after purchase at the end of the

trail period.

________________________________ _____________________________________

Audiologist/Date Patient/Parent/Guardian

Medical Waiver (if applicable)

(Medical clearance from a physician required for children under the age of 18)

I have been advised by Purdue University that the Food and Drug Administration has determined that my best health interest would be

served if I had a medical evaluation by a licensed physician (preferably a physician who specializes in diseases of the ear) before

purchasing a hearing aid. As a consenting adult over the age of 18, I do not wish to have a medical evaluation before purchasing a

hearing aid. To the best of my knowledge there are no conditions that would prevent me from using a hearing aid.

_________________________________ ____________________________________

Patient Signature Date

117

Purdue University Audiology Clinic

Hearing Aid Repair Request

Date: ________________ Name: _________________________________________

Address:________________________________________________________________

________________________________________________________________

________________________________________________________________

Telephone: ______________________________________________________________

Which hearing aid are you having problems with (please circle)? Right Left Both

What is wrong with your left hearing aid?

___ Dead

___ Weak

___ Noisy

___ Distorted

___ Feedback

___ Broken tubing

___ Broken battery door

___ Broken volume control

___ Broken or cracked faceplate

___ Other ________________________

What is wrong with your right hearing aid?

___ Dead

___ Weak

___ Noisy

___ Distorted

___ Feedback

___ Broken tubing

___ Broken battery door

___ Broken volume control

___ Broken or cracked faceplate

___ Other ________________________

I approve the necessary repair costs below (check one or both items):

___ $225.00 (each) if my hearing aid is out of warranty and needs to be sent to the

manufacturer for repair. This repair cost includes a one year warranty.

___ $25.00 (each) for in-house repairs. This does not include a warranty.

NOTE: Additional charges apply if the shell of the hearing aid is broken – we will call if

the repair charge will exceed $225.00.

Hearing Aid Return: ___ Have someone contact me when my hearing aid is ready

and I will pick it up at the main office (8AM – 5PM)

___ Have my hearing aid mailed to me after the repair (address

above). A $15.00 shipping fee will be added to in-house

repairs that are mailed.

___ I don’t know yet, call me when the hearing aid is repaired.

127

OSHA Clinic

Expected Rating by Year Start:______

I II III IV End: ______

3 4 4 5 No.: ______

(Clinic set-up, Confidence, Motivation to learn/implement feedback) Doc: ______

Video set-up/operation 4 4 5 5 Total:______

Audiometer Daily Biological & Listening Checks 4 4 5 5

3 4 4 5

OSHA Evaluation Skills

Case History 3 4 4 5

Instructions

Otoscopy 2 3 4 5

Determination for need for cerumen mgmt 3 4 4 5

Determination of need for age correction 3 4 4 5

AC threshold testing 3 4 5 5

Determination for need for masking 3 4 5 5

Test interpretation 3 4 4 5

OSHA Recommendations 3 4 4 5

Time Management 3 4 4 5

Instrumentation 3 4 4 5

Initiative 3 4 4 5

Collaboration with colleagues 3 4 4 5

Patient follow-up 3 4 4 5

Explanation of Results 3 4 4 5

Treatment Skills

Ear impressions 2 3 4 5

HPD Verification 2 3 4 5

Documentation

(format/grammar/typos/readability and accuracy)

Data Entry

Chart notes 5 5 5 5

Time Management 3 4 5 5

Strengths Focus Areas Topics Discussed

1

2

3

Patient Interaction Skills

(Code of Ethics, Responsibility, Punctuality, HIPAA, Dress Code, Oral and Non-verbal communication, Infection control)

Professionalism Pass Fail

Preparation and Attitude

Files completed from last week done? Yes No

Purdue University Audiology Clinic Daily Feedback Sheet

Date: ___________ Student: ______________________ Supervisor: _________________________

0= Absent 1=Taught (specific direction required) 2=Emerging 3=Advancing 4=Present 5=Independent

137

FIRST STEPS CONTACT INFORMATION

CLUSTER D STAFF AND EDT CONTACTS

SPOE OFFICE FAX LINE

765-420-1406

SPOE MAIN LINE 765-420-1404 Cluster D SPOE Contacts Cell #

Office Extensions Email

INTAKE

Alyssa Beall 765-860-6284

ext. 8504 [email protected]

Kat Noe 765-491-0230


Kristin Sosa 765-490-1097


Rachel Garcia 765-409-1520


Wendy Weintraut 765-490-3287


ONGOING

Addie Rowan 317-691-5454


Amy Hill 317-459-3609


Ana Torres 765-609-2053


Ashley Gray 765-412-1380


Augustine McAdams 574-808-8293


Danielle Valdez 765-426-5796


Diana Ortega Monge 765-656-4208


Kaylah Jordan 269-362-0058


Mariela Wheeler 314-974-5691


Samantha Lowry 765-450-9545


Sonja Wood 765-413-1206


Susie Luyster (LPCC Coordinator) 765-434-5572


INTERN Megan Boardman 765-420-1404

[email protected]

ADMIN Tangie Armstrong, SPOE Supervisor 225-302-0014


Charissa Darland, OSC Supervisor 765-250-6010


Junea Jones, Admin. Assistant 765-420-1404


Clare Mann -1st Kids, Director 219-805-7074

219-662-7790 ext. 227 [email protected]

Katie Callan - 1st Kids, Human Resource 630-696-2370

219-662-7790 [email protected]

Scheduler for AT

Elena Diaz 765-420-1404


ASSESSMENT TEAM Cell # Fax # Email

Joyce Sanford, ST 765-714-2500

[email protected]

Martha Burrows, OT 317-501-8104


Janine Huffman , PT 765-730-3300

[email protected]

Vicki Diehl, PT 765-714-3117


Melissa Walker, DT 765-513-1066

[email protected]

Rachel Hatcher, ST 317-417-0299

[email protected]

Wendy Bruce, PT 574-286-1184

[email protected]

Sharon Zaugg, OT 574-527-0093

[email protected]

mailto:[email protected]






















138

GLASS

2300 Cason Street

Lafayette, IN 47904

Phone: 476-2900

LOCAL SCHOOLS

EARHART ELEMENTARY SCHOOL

3280 S 9th Street

Lafayette, IN 47909

Phone: 449-3600

EDGELEA ELEMENTARY SCHOOL

2910 S 18th Street

Lafayette, IN 47905

Phone: 772-4780

GLEN ACRES ELEMENTARY SCHOOL

3736 Kimberly Drive

Lafayette, IN 47905

Phone: 771-6150

MIAMI ELEMENTARY SCHOOL

2401 Beck Lane

Lafayette, IN 47909

Phone: 7724800

MILLER ELEMENTARY SCHOOL 700 S 4th Street

Lafayette, IN 47901

Phone: 476-2930

MURDOCK ELEMENTARY SCHOOL

2100 Cason Street

Lafayette, IN 47904

Phone: 771-6100

VINTON ELEMENTARY SCHOOL

2101 Elmwood Avenue

Lafayette, IN 47904

Phone: 771-6410

SUNNYSIDE MIDDLE SCHOOL

530 North 26th Street

Lafayette, IN 47904

Phone: 771-6100

TECHUMSEH JR HIGH SCHOOL

2101 S 18th Street

Lafayette, IN 47905

Phone: 449-3600

JEFFERSON HIGH SCHOOL 2101 S 18th Street

Lafayette, IN 47905

Phone: 772-4700

OAKLAND HIGH SCHOOL

611 S 21st Street

Lafayette, IN 47905

Phone: 771-6130

CUMBERLAND ELEMENTARY SCHOOL

600 Cumberland Avenue


Phone: 464-3212

HAPPY HOLLOW ELEMENTARY SCHOOL

1200 N Salisbury Street


Phone: 746-0500

WEST LAFAYETTE JR/SR HIGH SCHOOL

1101 N Grant Street


Jr. HS office: 746-0404 Sr. HS office: 746-0400

BATTLE GROUND ELMENTARY SCHOOL

303 Main Street

Battle Ground, IN 47920

Phone: 567-2200

BURNETT CREEK ELEMENTARY

5700 N 50 W


Phone: 463-2237

COLE ELEMENTARY SCHOOL

6418 E 900 S

Lafayette, IN 47909

Phone: 523-2141

DAYTON EMENTARY SCHOOL

320 College Street

Dayton, IN 47941

Phone: 447-5004

HERSHEY ELEMENTARY SCHOOL

7521 E 300 N

Lafayette, IN 47905

Phone: 269-8280

KLONDIKE ELEMENTARY 3311 Klondike Road

West Lafayette, In 47906

Phone: 463-5505

MAYFLOWER MILL ELEMENTARY SCHOOL MINTONYE ELEMENTARY SCHOOL

139

200 E 500 S

Lafayette, IN 47909

Phone: 538-3875

2000 W 800 S

Lafayette, IN 47909

Phone: 538-2780

WEA RIDGE ELEMENTARY SCHOOL

1333 E 430 S

Lafayette, IN 47909

Phone: 471-9321

WOODLAND ELEMENTARY SCHOOL

3200 E 450 S

Lafayette, IN 47909

Phone: 269-8220

WYANDOTTE ELEMENTARY SCHOOL

5865 E 50 S

Lafayette, IN 47909

Phone: 772-7000

EAST TIPP MIDDLE SCHOOL

7501 E 300 N

Lafayette, IN 47905

Phone: 589-3566

KLONDIKE MIDDLE SCHOOL

3301 Klondike Road


Phone: 463-2544

BATTLE GROUND MIDDLE SCHOOL

6100 N 50 W


Phone: 269-8140

WAINWRIGHT MIDDLE SCHOOL

7501 E 700 S

Lafayette, IN 47909

Phone: 269-8350

SOUTHWESTERN MIDDLE SCHOOL

2100 W 800 S

Lafayette, IN 47909

Phone: 538-3025

HARRISON HIGH SCHOOL

5701 N 50 W


Phone: 463-3511

WEA RIDGE MIDDLE SCHOOL

4410 S 150 E

Lafayette, IN 47909

Phone: 471-2164

McCUTCHEON HIGH SCHOOL

4951 US Highway 231 S

Lafayette, IN 47909

Phone: 474-1488

appendix of forms - purdue university · appendix of forms. 86 rev july 2010 your name ... serves...

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