Yes   No   An audiological report documents a permanent hearing loss in
                 excess of 20 dB better ear average in the speech range (500, 1,000,
                 2,000 Hz), unaided, or

Yes   No   A history of fluctuating hearing loss which has interrupted the
                 normal acquisition of speech and language and continues to
                 adversely affect educational performance.
 

DEFINITIONS:

"Adversely affect the student's educational performance" means that the
student's ability to learn in the regular education setting remains severely
affected even when classroom interventions are applied or accommodations
provided to the degree that the student needs special education and related
services.

Student Name: _________________ CST Date: __________