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Assessment Basics for the School Nurse: Hearing Screens

Screenings are one of the most important jobs school nurses do. We are often the first to determine that a student may need glasses or hearing assistance to improve their education.

The who and the when of screenings will depend on the state and district in which you are working. To find out who needs what screenings and when you can Google “mandated school screenings x state name” It will usually take you to your state department of health where you can see the information regarding mandated screenings. Here is an example of my state department of health website regarding screenings:

For now I want to narrow it down to just hearing screens (vision screens are in another post). For my state (PA), I do hearing screens on kindergarten, 1st grade, 2nd grade, 3rd grade, 7th grade, 11th grade, anyone new to the district, and any students needing an IEP evaluation/renewal. If they had a hearing screen already at their yearly checkup then they can be exempt unless there is a concern.

Types of hearing tests

  • Pure-Tone Testing: You might remember putting earphones on and raising your hand whenever you heard the “beep.” This is pure-tone testing. It is sometimes referred to as “air conduction testing” since the sounds go through your outer and middle ear. This test helps find the quietest sound you can hear at different pitches, or frequencies. Having earphones on lets the sounds go to one ear at a time. This is sometimes done in a sound booth at the ENT or audiologists’ office. This is generally what you will find in a school setting as well.
  • Speech Testing: Speech testing is a test to assess how well a person can listen and repeat words. This is often done in a sound booth with headphones on by a speech therapist. It sometimes is done in a noisier place to assess if you can separate background noise from other sounds. The Pilot audiometer is a type of speech testing.
  • Tests of the Middle Ear: Tympanometry, acoustic reflex and static acoustic impedance measure the workings of the outer, middle and inner ear. These usually involve a probe in the ear canal to measure muscle response, eardrum movement and air levels in the ear canal. These will usually be done at the pediatrician or ENT/audiologist.
  • Auditory Brainstem Response (ABR): Measures the brainwaves associated with hearing and cochlear function. This can be done on younger children who are unable to actively participate in a hearing test (like newborns in the hospital), or to assess if the hearing loss is due to a brain pathway issue vs a structural ear issue. This is performed by audiology usually
  • Otoacoustic Emissions (OAEs): The OAE test is used to find out how well your inner ear, or cochlea, works. It measures otoacoustic emissions, or OAEs. These are sounds given off by the inner ear when responding to a sound. There are hair cells in the inner ear that respond to sound by vibrating. The vibration produces a very quiet sound that echoes back into the middle ear. This sound is the OAE that is measured. This is often used for the newborn hearing screens in the hospital and for pre-school students. OAE is not as useful for people over 5 years old but can be used if needed for someone who is unable to participate in a hearing screen.


  • Audiometer: There are tons of brands and styles of audiometers. The MAICO is the most popular that you will see. They range in price from about $1000 up to $3000 depending on which model you choose. The Pilot is also made by MAICO but performs the speech test as opposed to the pure tone test – it is around $3400 on Welch-Allyn is also a popular manufacturer of audiometers.
  • OAE machine: Usually for pre-k hearing testing, costs approximately $5000+ depending on the model and type of kit purchased.
  • Small toys or blocks and a bucket to drop them into (optional): Some audiologists and/or nurses like to use small toys to drop in a bucket instead of the raising hands for the hearing tests on the kinder or pre-k kids. I have a set of small colored blocks and a bucket to use if I think it will work better.
  • Otoscope: You may want to look in the student’s ears to assess for wax occlusion or abnormalities. This is optional as some states or districts do not allow school nurses to assess ears in this manner.
  • A very quiet space: It is extremely important to have the quietest space possible to perform hearing screens. Sometimes even the noise of the refrigerator humming or the air conditioner will interfere. This is why audiologists usually have a sound booth for optimal testing environment. If you have a little noise just be aware that the student may be unable to hear the quietest tones during the test.
  • A comfortable seat: You should have a chair and preferably a desk for the student to sit at during the test when they can feel comfortable and relaxed but also be able to turn away from you so the don’t see you pushing the buttons on the machine.
MAICO Audiometer
Welch Allyn OAE


Basic procedure for pure tone hearing “sweep” test (aka “rapid” test):

  • Allow the audiometer to warm up for 15-20 min
  • Have the student sitting comfortably in a position where they can not see you working the machine and giving inadvertent clues to the sounds but the tester can also observe their face for responses.
  • Instruct the student prior to placing headphones that they should hear a “beep” and when they do they should raise their hand then put it back down. Alternatively, they can drop a toy into the bucket if they hear the beep.
  • Place the headphones on the student with the red earpiece on the right and the blue earpiece on the left.
  • Set the frequency to 1000 Hz and the decibels to 55 dB then deploy a tone.
  • Decrease the dB to 40, then 25 giving one tone for each.
  • Once at 25 dB test the frequency at 2000, 4000, 250, 500
  • Repeat process for the other ear.

Basic procedure for threshold test

  • Begin with frequency at 1000 Hz and decibels at 50 dB
  • Decrease decibels by 10 until the student no longer indicates they can hear the tones.
  • Increase decibels by 5 until they hear the tone again.
  • At 25-30 dB start increasing the frequency to 1000, 2000, 4000, then 250 and 500.
  • Note if the student does not indicate that they hear the tone.
  • Repeat procedure for the other ear.

Pass/Fail criteria

Per the Pennsylvania Department of Health (your state or district may have different criteria):

  • For the sweep test, a child not hearing two or more tones at 25 dB in one or both ears should be given a threshold test that day or within one month.
  • For the threshold test, a student whose threshold test shows a hearing level of 30 dB or more for two or more tones in one or both ears, or 35 dB or more for one tone in either ear, shall be referred to the family’s provider or usual source of care for a complete ear examination. A complete ear examination means otologic assessment and audiometric tests. It is the family’s responsibility to arrange this examination.

Tips & Tricks

  • According to the PA Dept. of Health instructions, you should allow the audiometer to warm up for 15-20 min.
  • Always make sure you have the quietest space possible for hearing screens. My personal office is not in a quiet location but I scouted the school for the best spot and an admin is kind enough to loan his office for my hearing screens. I also have set up shop in the kindergarten closets because they are large, insulated, and fairly quiet.
  • Before beginning the test make sure that the student fully understands the instructions. If there is a language barrier use your translating services or interpreter to ensure they understand what to do.
  • Red = right ear, blue = left ear
  • As mentioned, you can either have the student rise a hand when they hear the tones or make it fun and have them drop toys or blocks in a bucket when they hear the tone.
  • Be careful because the student might see you pushing the buttons on the machine and know when to raise their hand even if they didn’t hear the tone.
  • You can often observe the student’s face and mannerisms and tell when they hear a sound but are unsure. They may look questioning, or look around or stop to try and listen harder.
  • If you are permitted in your district, you can look in a student’s ears and determine if they have excessive or occluding wax that might be interfering with the hearing screen, or possibly fluid in the ear that could affect it. If they do then they would then need to be referred to their doctor for further evaluation as we are not able to remove the wax nor are we able to diagnose an ear infection or abnormality.
  • Clean the headphones between students with a lysol wipe.
  • Audiometers should be calibrated yearly. Ours usually go out for calibration at the end of the school year and we get them back in september/october. You would make arrangements with the dealer of the audiometers for calibration.

Are any of you hearing screening experts? I would love to hear some tips and tricks if you know of any! Please follow my blog and comment with any thoughts!

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Published by Emme Mauer M.Ed., BSN, RN, CSN

Mom to two preemies, anxiety sufferer, postpartum depression survivor, and school nurse extraordinaire.

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