ࡱ> ?A>U bjbjnn *aa]]BB8%:HHH$ ""BBHH9hhhjB8HHhhhzhH+EJvh0%h_#_#h_#h(h-g%_#B :  HEARING IMPAIRED CERTIFICATION FORM Name of Student:__________________________________Birth Date:____________________ An otologic examination was completed on the above named individual on ________________. Date The results indicate a hearing impairment that is not based solely on behavior relating to environmental, cultural, or economic differences. Health of Ears: ________________________________________________________________ Hearing Loss: _________________________________________________________________ Does the hearing loss adversely affect his/her educational performance? Yes_____ No _____ Comments: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Otologist: _____________________________________________________________________ Print Name Otolaryngologist: _______________________________________________________________ Signature Address: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Phone: ___________________________________ Fax: _____________________________ If your audiologist completed a hearing test, please send a copy of the results (AIDED AND UNAIDED). If you have any questions, please feel free to call at (810) 648-2200 Ext. 127. PLEASE RETURN FORM TO: Rebecca Lipka, MA, CCC-A Educational Audiologist Sanilac Intermediate School District 46 N Jackson Street Sandusky, MI 48471 (810) 648-2200 Ext. 4120 Fax #: (810) 648-2275      FILENAME AUD Form 3 HI Cert Form Page  PAGE 1 of  NUMPAGES 1 1/2020  Special Education Services 46 North Jackson Street Sandusky, Michigan 48471 810-648-2200 /01 Kbcdq| !#$./FGMNTUVW[\fghiؽ¶{o{ojh7CJU*h8MCJmHnHu*h7CJmHnHu h7CJjh7CJUh@V&jh@V&U h8Mh7 h8Mh8M h8M]h8Mh75\]h756CJ\ h7] h7>*]h76>*]h7jh7CJUmHnHu+./01| }  ~ % } ~ 3 D @  # KLcd}gd8M$a$$ a$&$$d %d &d 'd N O P Q a$ "#Hjkrstvgd8M$a$ijkqrstuv h8Mh7 h7CJ jh7Uh@V& h8MCJh7 h7CJ (/ =!"#$% 2Dd6w%yN  C *Aclip0000bQԨd4n3nlDndQԨd4n3nPNG  IHDR!.&1gAMA|Q pHYs-"IDATxK8Z`*HHm5(0`vU@bS^ HW$9I{ _qrĂ^U^U^U^U^U^U^[T~26O( eDO(u+#B~Ev_E[*+ Je (R  _0dH+ľ\A7r%D\ #U ,8x2͸X[ɥv-LA$S3(^I=)$Y-QQIEKJ 3{e >#m/TDLYaAm(QgN7pe+gUVX*ca+'IXΔx6V* |?JvUieC 9v* $ )}J*, O*zw*I< iepQC` (xWa* S:{Hr&qlt %m"l\7%MYI듛/a(RyB|flÏj@}={ZzX9rP _Ϻ)rP wR@(vp,|X*D3ǂPPQ=uU QlZ  ~^]%ѫ٬mbjÛ8smb1~^`O $*ĖF^+`e>! p/f,obMobHx(@!+@!KrZ Y_41<(}nc[4%$CWȲR8Brr +=&A1Zi"+6X0E9DHyB!&1|Vڳj\(lU'Qjbѕ)arUlkq:d(|?+(|xl*,k ?wc /yCfu 5ckn~SEt.)<~ ^7BNtUFC"OFSUF:LaN,vc2oI@8>ͺB2&u"O4XnFoV<60\S I4Zѧ<04V@'J~ꁝnd&JSԳd^Ox^gJauMQTUeY+QU"J| X<2 mzVYӔ;r9EҊD=כ"6n<|8+I~S'ewL[ofc"ȵ" [SlSgNa6H_5w8F CKM ݺLp[Be[QZpѦ8EQ55%(iLqU&7K ie`Ljh[)ț E;w)|^RG{DAw+#jA *8QەFJM =g}>ЧvBr'|]y]|DiR&w:='^W)˗g_R({׀dv?6؞Äo\qҌe]re>ӂ‘)*.0}KQR: & ^Am%r")T\7SR2i[D&У";#(7bF}Cg!]-, % sN;9 B^iVd@f?bN<* rk"eɀ f%]+Wԋ˙龋ߤsl@T mrV?mGv+$r ޿it뛎uu eU-h2mV3kK˃"TJ*t|JoapL!gR Q4k,w($rJ_ȣ" ]7e0ye@v9xEI *e~}CYe(=P[(*.)cDqG e(PLxʴQ@iցƨҗ*BIP*% Tp?R>B[Je*V߳ݮ@×U* TN*$9yEV*XN% TSHVQ+O{Zr2G^eJ Q@2+v+V PHa?tG]Vz@Y )<"e1zIae)}^Re,TSH2Y2"Dn L0eH*8]@^28Wt"y7sE_ @a=[*7a\Cu^98L>sE"4Tvo1N(-]xQاPl;SX2Q 5BB2@Y] (R6** e:J7Rek!PF2*xf*8%i-!Qk5d G QN=Ǽl"%YSVY12ſ{*ѲF5"]QF|T)kpkY3H)ݡU R S5tI$5WYeTTBxABD% 3H(bMޏmSڪ1@UUCuWSփ%(*ݎoTgp&?XSLeVa, Z2Boy, "p} TDbn3qF?LWdYx2ߗ&×X?INaG ќ3^n}|e7Pl' YIgh6VASpDANJ1aSVkJX(bz*^V124mCVF{I+w%ЛrV}Z^#>3oQ$:)K2ߵJWF]e0E!rUFd\i3/R@Qz_La0ev *W\aT75\|w|dRt%%keّbXY:}pPV82:6/F 'geiSR#GeZj7E)RS8Cy{^A)C;.[B2=DYV\/zA3%jS*ů4ڳ}NVdDS1fI"JXΕ^DROjDik9PT}ky/覿J;ʥ cpw/̬F!ǾϣfA#r) *cDE)ZY,;>O&AE.:ehcG1`+h[ďdMDQ emW=JQ)ms e>SCe0b_tIC~ĝ." )R0t,Y6P17cJzyF1o"O5c3g_Wh^Q0~yzW 1FZP~\KuNJ*m2)>P" K (`ՠ7)T"_b=κ]tKI0- _sN******E*Lc}BL'S䷛#o.&D-v<,v5hXV杫.@Rn$11I5O3(3Ő,hج AcDWZY?[f P}9EQ`pC Z!JQ moK!nQ;W )ZU.к/Pn~0*ݢ#>j]~ڼ243Ǫ bI5%MJfE;Nt@VjcvDŴS?Q԰Ϣ,;.խdQc}&IZX t1wYEOASES?\E]B}mbZr VXUjX513wc2ѼI\!:Sbj۔E I5ܪddm2j#P~B5 WZ`U.{+K.(B)6UTMLЍo+Y+S,bSGFD(x,kl^{XeE9BU&wJsTfzN TZ2jEO+ K, j{e6 EςMЕVP-\?>m@{ż*HQ2GV+ͪA~Qh.񨈨b(kySXB̫;B ծq1 )^z 4.75W'-YmW ژ)Sc8ZM22*Z/W$1ۏ+2eh~_}r'~L䏕*4n+29Eܨq?+}9PJt׍҃dϔ9̀zv8S +'c2jpn9`y7 R'ۜ'pί)e /N+EeWNN_4jQi6Obx{-6xxַ\ARE'+G5[VB]N_9 U]#5rl`ٶƤ 8U;W\S},JkeR(x3N O}cgAb0^irqAv-Qg^1%abpni^tǼUf|-`sc}^]^” rNf h^A}zNzR&)Ž7:j_kMno2Wp_?,2LA88WyWyWyWyWyWyWyW )R}Km?|KʷԒ߲|eGCfIENDB`s2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH <`< NormalCJ_HmH sH tH DA`D Default Paragraph FontViV  Table Normal :V 44 la (k (No List <J@< Subtitle$a$ 56CJ4@4 Header  !4 @4 Footer  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<v \\_ TT\\\_i   /6=?DOQ_!8@(  V  # "? 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