Audiology Referral

If you would like to have your student considered for USDB audiology services, please complete the form below.

Referral Policy for USDB Audiological Services

Submission Date:
Student Name:*
Student Date of Birth:*
Gender*
Parent Name:*
Parent Address: (Reports will be sent here)*
Second Parent Name
Second Parent Address:
Student is Enrolled in*
Please specify which school district if District is selected.
Right Ear First Screening*
Left Ear First Screening*
Date of First Screening*
Right Ear Second Screening*
Left Ear Second Screening*
Date of Second Screening*
Does the child have one of the following diagnosis? Check all that apply
Already diagnosed with a hearing loss by a professional*
Name of Person Referring*

Step 1 for Devin

Reassign or Continue with the referral*
If you select to Continue enter your email address.

Referral Status

Select your name, unless you wish to reassign the referral to another Audiologist.
Select your email, unless you wish to reassign the referral to another Audiologist.
Status of Referral - 1*
Skip Consent Form:*
Consent form sent on Date/Time*
:  
Consent form due Date/Time*
:  
Needs Correct Contact Information:*
Requires 3rd party action:*

Referral Status - Step 2

Status of Referral - Step 2*
Consent Form Received?*
3rd Party action resolved?*
Correct Contact Information received:*

Upload any supporting documents to TIMS.

Parent Name:*
Parent Address:*

Finalized Referral Status

Status of Referral - Step 3*
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