KNOX COUNTY SCHOOLS
System-Wide Screening – Hearing Services
101 East Fifth Avenue – Room 202
Knoxville, Tennessee 37917
MEDICAL EVALUATION OF SUSPECTED HEARING PROBLEM
Student Date of Birth / /
Your child’s hearing was tested at school recently by a Knox County Schools audiologist. The attached results indicated
that he/she should be seen by your doctor or ear specialist.
Please take this form with you when you go for the appointment. Have the doctor complete this form and return it to us
in the enclosed envelope. This will assist us in serving your child effectively.
If you have questions or concerns, you may contact me at 594-3722. Your prompt attention to this form is appreciated.
, Audiologist CCC-A
Knox County Schools Date
BELOW TO BE COMPLETED BY DOCTOR
MEDICAL REPORT – IMPRESSIONS & RECOMMENDATIONS
Physician's Signature Address Date of Exam