Hearing and Vision Screening Equipment Request Survey

Screening equipment is available from the Ohio Department of Health Children’s Hearing and Vision Program. Equipment may only be provided to early learning centers, health departments and schools.

The equipment must be picked up by the early learning center, health department or school and dropped off by the early learning center, health department or school within the two month lending time period.

Please complete the below information to request equipment. Following the submission of this form, you will be contacted by an ODH staff member.

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1. Please complete the following information to request an equipment loan.

Requestor Name:

Name of Individual Conducting Screenings:

School or Agency Name:

School or Agency Address:

City

State:

ZIP:

County:

Email Address:

Phone Number:

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2. Select the grade level(s) you are responsible for screening. Select all that apply.

Preschool

Kindergarten and/or First Grade

Second Grade and Above

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3. Select the type of screening equipment you would like to borrow.

Hearing Screening Equipment

Vision Screening Equipment

Both

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4. Select the preferred timeframe you would like to borrow the screening equipment.

August 1- September 30

October 1- November 30

December 1 - January 31

February 1- March 31

April 1 - May 31

Question Title

1. Please complete the following information to request an equipment loan.

Question Title

2. Select the grade level(s) you are responsible for screening. Select all that apply.

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3. Select the type of screening equipment you would like to borrow.

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4. Select the preferred timeframe you would like to borrow the screening equipment.

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5. Estimate the number of students who will be screened using the equipment.