2025 Vision & Hearing Form

Vision & Hearing Form

ALL children over the age of 4 years as of September 1, 2025 are required to be screened for Vision & Hearing during the calendar year 2025. You may submit results from your child's doctor or use this form to have your child conveniently tested here at school.
TX Dept. of Health Requirement : Vision & Hearing

Required for all 4 & 5 year olds, optional but recommended for 3 year olds
Tacquard & Associates - Child Health Consultants
Jennifer Tacquard Machann
5114 Balcones Woods Dr. #307-235, Austin, TX 78759
(512) 910-4321 * vhsaustin@gmail.com

The Special Senses and Communications Disorders Act requires all schools to show proof that Vision & Hearing screening has been done on all 4, 5 and 6 year olds -> must be done three years in a row. Strongly encouraged are children ages 3 1/2 to 4 years. As you know, early identification and intervention are critical for successful learning.

Because of this law and in keeping with the quality your school provides, we have again chosen the above group of professionals to perform the screening on the morning of Thursday, September 25. Vision is screened by playing a "matching game", making letter identification unnecessary. Hearing is screened by playing an "airplane pilot game". The school will receive a copy of the results for their records and one to send home to the parent. Parents do not need to be there.

If your child is 4, 5 or 6 years old and you prefer to have this done elsewhere, please give the school a copy of a screening - done in 2025 - by the screening date above. Important: Texas Dept. of Health requires that the school have an "official document" with the following information: student's full name, date of birth, type of screening, screening date and screener's name.

Texas Dept. of Health also requires the Vision results be recorded for right and left eyes individually and that the Hearing results must be an audiometric screening in right and left ears individually at 25 dB (or less) at 1000, 2000 and 4000 Hz. An Otoacoustic Emissions Test (OAE) is not accepted.

The TDOH requires schools to submit this screening information yearly.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Please check which screenings you want your child to receive at RBCS:*

Both Vision & Hearing Tests ($45)Vision Test Only ($30)Hearing Test Only ($30)I am choosing not to participate because my child will be tested at another location. (Next section required.)
Complete this section if your child is being tested at their doctor's office: I understand that vision and hearing screening is required for my child during the calendar year 2025. I have checked with my child's doctor to be sure they offer vision and hearing screening. An appointment is scheduled for date and I will provide appropriate records to the school immediately following the appointment date.
If your child has already been TESTED IN 2025, you can upload the results here. Please refer to the guidelines above to ensure that you are providing complete and valid records.

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The following information is helpful if your child is participating in the screening: Do you have any concerns about your child's vision or hearing? Are there any family history of vision or hearing problems?
IMPORTANT: Children who wear glasses should wear them for the screening.

If you have checked needed screenings above, your tuition account will be charged for the selected tests and RBCS will remit payment to Tacquard & Associates on your behalf.
Parent or Guardian Signature*

Clear
Email*
example@example.com
Date*

MonthDayYear
Date
Should be Empty:

Vision & Hearing Form

TX Dept. of Health Requirement : Vision & Hearing