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00 Hz 4000 Hz Right Ear (in dB) Left Ear (in dB) Did the student pass the screening? If they failed, were they re-tested on a different day? If yes, record the date of re-testing. Did the student pass or fail the re-screening? OAK HILL ACADEMY PURE TONE HEARING SCREENING FORM Student Name: Date: Examiner: Core/Teacher: Note: Passing threshold is 20db at 1000Hz & 2000Hz, & 25db at 500Hz & 4000Hz. 500 Hz 1000 Hz Right Ear (in dB) Left Ear (in dB) Did the student pass the screening? If the.

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