Washington State School for the Blind (WSSB)
Center for Deafness and Hearing Loss (CDHL)

Children Aged Birth to 3 with Sensory Disabilities
REGISTRY FORM

The purpose of this form is to gather demographic information on the children aged birth to 3 who are blind/visually impaired, deaf/hard of hearing, or both deaf/blind in the state of Washington. It is not a referral to a particular program nor a request for technical assistance or consultation.

If you have any questions completing this form, please contact DeEtte Snyder (BVI) DeEtte.Snyder@wssb.wa.gov or Kris Ching (DHH) Kris.Ching@cdhl.wa.gov

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Required fields marked with '*'

*Registry Type:

*Child’s Last Name: Required *Child’s First Name: Required *Date of Birth: Required

*Parent(s)/Guardian(s) Name: Required *Phone Number: Required

*Address: Required *City: Required State: *Zipcode: Required *County: Required

*School District: Required Language(s) Used in Home:


Hearing Information


Audiology report on file with EI agency: *Date of Diagnosis: *Audiologist’s Name:

Medical Records on Order:

Type of Hearing Loss: (if known, check all that apply)

Conductive

Sensorineural

Mixed

Unknown, Further Testing Needed

Hearing Levels/Degree of Hearing Loss: Left (Degree ) Right (Degree ) Further Testing Needed

Amplification (hearing aids, cochlear implant): Left: Right:

Family/Caregiver Hearing Status: (check all that apply) Hearing Hard of Hearing Deaf


Visual Impairment Information


Eye report on file with EI agency: *Date of Eye Exam: *Ophthalmologist’s Name:

Medical Records on Order:

Vision Condition(s):(if known, check all that apply)

Cortical Visual Impairment (CVI) or Delayed Visual Maturation (DVM)

Retinopathy of Prematurity (ROP)

Albinism

Aniridia

Coloboma

Leber’s Congenital Amaurosis (LCA)

Retinal Disorder

Nystagmus

Optic Nerve Hypoplasia (ONH)

Anophthalmia/microphthalmia

Cataract

Corneal defects 

Retinoblastoma

Glaucoma

Strabismus

Other:

Unknown, further testing needed

Wears: Glasses Contacts Prosthetics


Early Intervention Services


*Current IFSP Date (if completed): Required *Name of Agency Providing EI Services: Required

*Lead FRC or Assigned FRC: Required *Email: Required *Phone: Required

Primary EI Provider (if known): Email: Phone:

TVI (if known): Email: Phone:

TOD (if known): Email: Phone:

Agency providing TVI/TOD Service:(if known)

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