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FORT LA BOSS SCHOOL DIVISION PREPARING STUDENTS FOR THE FUTURE www.flbsd.mb.caINDIVIDUAL SCHOOL HEARING SCREENING RECORD Name:School:OutputFrequencyRightRightRightLeftLeftLeftResults:500Hz2000Hz4000Hz4000Hz2000Hz500HzExaminer:Comments:Birth×Date:Grade:Screening×1:Intensity (dB)Pass:Fail:Screening×2:Intensity (dB)Date:

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Record formdocx is a document used to keep track of important records.

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Information such as name, date, and description of the record must be reported on record formdocx.

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