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, city, ZIP code and county. Enter the name and telephone number of the individual submitting the report. Enter the date the report is submitted. Submit one cumulative annual report from each school district, health department or other agency responsible for hearing screening. Submit this report to the Department’s Vision and Hearing Program by June 30 of each year. PLEASE TYPE OR PRINT LEGIBLY. CHECK ALL COMPUTATIONS. THIS FORM IS USED TO COMPILE STATEWIDE STATISTICS. THANK YOU FOR YOUR COOPE.

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