Live Virtual Hearing and Vision Training Request Survey

The Ohio Department of Health, Children's Hearing and Vision program, offers hearing and vision screening trainings. There is no registration fee for these trainings and no continuing education credits are given.

Live virtual trainings will be provided by ODH staff, time and resources permitting.

Please be aware that hearing screening training requires two hours of virtual instruction and vision screening training requires three hours of virtual instruction.

Please complete the below information to submit your live virtual screening training request. Following the submission of this form, you will be contacted by an ODH staff member.

Question Title

1. Please complete the following information to request a live virtual screening training.

Requestor Name:

School or Agency Name:

School or Agency Address:

City

State:

ZIP:

County:

Email Address:

Phone Number:

Question Title

2. Select type of requested screening training.

Hearing Screening Training

Vision Screening Training

Both

Question Title

3. Provide number of participants to be trained. Please note the maximum is 25 participants.

Question Title

4. Select group type to be trained. Those trained must be at least eighteen years of age.

Audiologists

Health Aides

Licensed Practical Nurses

Public Health Nurses

Registered Nurses

Speech Language Pathologists

Nursing Delegates

Medical Assistant Students

Nursing Students

Volunteers

Other (please specify)

Question Title

5. ODH requires that you have arranged with a local school or medical provider for screeners to assist with or conduct screenings as a follow-up activity to the training.

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:

State:

ZIP:

Email Address:

Phone Number:

Question Title

6. Projected number of children to be screened for hearing.

Question Title

7. Projected number of children to be screened for vision.

Question Title

8. Select the projected month you would like training offered.

January

February

March

April

May

June

July

August

September

October

November

December

Question Title

9. Please select the grade you would like vision screening training.

Preschool (3 hour training)

School-aged (4 hour training)

Both (5 hour training)

Question Title

1. Please complete the following information to request a live virtual screening training.

Question Title

2. Select type of requested screening training.

Question Title

3. Provide number of participants to be trained. Please note the maximum is 25 participants.

Question Title

4. Select group type to be trained. Those trained must be at least eighteen years of age.

Question Title

5. ODH requires that you have arranged with a local school or medical provider for screeners to assist with or conduct screenings as a follow-up activity to the training. Please provide the below information for the school or medical provider where screeners will conduct screenings.

Question Title

6. Projected number of children to be screened for hearing.

Question Title

7. Projected number of children to be screened for vision.

Question Title

8. Select the projected month you would like training offered.

Question Title

9. Please select the grade you would like vision screening training.

5. ODH requires that you have arranged with a local school or medical provider for screeners to assist with or conduct screenings as a follow-up activity to the training.

Please provide the below information for the school or medical provider where screeners will conduct screenings.