Screener Train the Trainer Request Question Title 1. Please complete the below information to request a Train the Trainer training. Requestor Name: * School or Agency Name: * School or Agency Address: * Address2 City: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * County * Contact Email Address: * Contact Phone Number: * Question Title 2. Please select the train the trainer training that you are requesting. Hearing Train the Trainer Training Vision School Age Train the Trainer Training Both Train the Trainer Trainings (School age for Hearing and Vision) Question Title 3. Are you interested in attending a Preschool Vision Screening Train the Trainer course Yes No Question Title 4. Please answer the below questions regarding Hearing Train the Trainer requirements. Yes No Are you a Registered Nurse (RN)? Are you a Registered Nurse (RN)? Yes Are you a Registered Nurse (RN)? No Are you an Audiologist? Are you an Audiologist? Yes Are you an Audiologist? No Are you a Speech Language Pathologist (SLP)? Are you a Speech Language Pathologist (SLP)? Yes Are you a Speech Language Pathologist (SLP)? No Have you completed hearing screenings on children in the school setting? Have you completed hearing screenings on children in the school setting? Yes Have you completed hearing screenings on children in the school setting? No Do you have access to the hearing screening equipment? Do you have access to the hearing screening equipment? Yes Do you have access to the hearing screening equipment? No Have you completed a hearing screening training provided by ODH? Have you completed a hearing screening training provided by ODH? Yes Have you completed a hearing screening training provided by ODH? No Are you 18 years old or older? Are you 18 years old or older? Yes Are you 18 years old or older? No Question Title 5. Please answer the below questions regarding Vision Train the Trainer requirements. Yes No Are you a Registered Nurse (RN)? Are you a Registered Nurse (RN)? Yes Are you a Registered Nurse (RN)? No Have you completed vision screenings on children in the school setting? Have you completed vision screenings on children in the school setting? Yes Have you completed vision screenings on children in the school setting? No Have you completed a vision screening training provided by ODH? Have you completed a vision screening training provided by ODH? Yes Have you completed a vision screening training provided by ODH? No Do you have access to the vision screening equipment? Do you have access to the vision screening equipment? Yes Do you have access to the vision screening equipment? No Are you 18 years old or older? Are you 18 years old or older? Yes Are you 18 years old or older? No Question Title 6. Please provide the below information for the school or medical provider where screeners will conduct screenings. Contact Name: School/Medical Provider: Address: Scheduled Screening Date: City/Town Email Address: Phone Number: Question Title 7. Estimated number of vision screeners to be trained yearly Question Title 8. Estimated number of hearing screeners to be trained yearly Next
