Chapter 246-760 WAC

Each board of school directors in the state shall provide for and require hearing and vision screening of children attending schools in their districts to determine if any child demonstrates reduced hearing or vision that may negatively impact their learning. Each board of school directors shall establish procedures to implement these rules.

The definitions, abbreviations, and acronyms in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "AAPOS" or "American Association for Pediatric Ophthalmology and Strabismus" means the national organization that advances the quality of children's eye care, supports the training of pediatric ophthalmologists, supports research activities in pediatric ophthalmology, and advances the care of adults with strabismus.

(2) "ASA/ANSI" or "Acoustical Society of America/American National Standards Institute" means the national organization responsible for publishing standards and technical reports that standardize acoustical terminology and measurements, as well as for developing consensus-driven industry standards.

(3) "Audiometer" means an instrument used to measure hearing acuity. It is commonly used in hearing tests, typically by presenting pure tones, speech signals, or other auditory stimuli to assess changes in a person's hearing ability.

(4) "Audiological evaluation" means a comprehensive diagnostic exam used to determine the type, degree, and configuration of reduction in hearing. This evaluation is performed by a licensed professional or specialist to diagnose and characterize hearing reductions and create an individualized treatment plan to address hearing needs.

(5) "Auditory acuity" or "hearing acuity," refers to how sharp or sensitive someone's hearing is. It can mean the ability to hear faint sounds, distinguish between different sounds (like pitch or loudness), and identify the direction from which a sound is coming from.

(6) "Calibrate" means to adjust and/or verify the accuracy of screening equipment to ensure it meets established standards. This process involves checking and fine-tuning the equipment to ensure it provides reliable and consistent results in assessing auditory or visual acuity.

(7) "Crowding bars" means four individual lines surrounding a single optotype.

(8) "Crowding box" or "surround box" means crowding bars on all four sides extended to form a crowding rectangle surrounding a single line of optotypes.

(9) "dB" or "decibel" means a unit of measurement used to express the relative intensity of sound. It is commonly used to quantify sound levels and describe hearing sensitivity.

(10) "Distance vision" means the ability of the eye to see images clearly at a calibrated distance.

(11) "Frequencies" refer to the different pitches of sounds, from low (deep) to high (sharp). Hearing is screened across a range of frequencies to identify reduced hearing at one or more frequencies.

(12) "Hearing screening" means a nondiagnostic test to identify if the person being screened needs to be referred for an audiological evaluation.

(13) "Hz" or "hertz" is the standard unit of measurement used for measuring frequency or pitch.

(14) "HOTV letters" means a test using the letters H, O, T, and V calibrated of a certain size used to assess visual acuity.

(15) "Instrument-based vision screening device" means a U.S. Food and Drug Administration approved instrument for vision screening that uses automated technology to provide information about amblyopia and reduced-vision risk factors such as estimates of refractive error and eye misalignment.

(16) "Lay person" means any individual who is conducting school-based vision screening other than a school nurse, a school principal or his or her designee, a licensed vision care professional, or an individual trained by and conducting vision screening on behalf of a nationally recognized service organization that utilizes a test-retest protocol for vision screening. This includes, but is not limited to, retired nurses, nursing students, parents, and school staff.

(17) "LEA vision test(s)" means a test used to measure visual acuity using specific symbols or numbers, designed for those who do not know how to read the letters of the alphabet.

(18) "Licensed vision care professional" means a licensed ophthalmologist or licensed optometrist.

(19) "Near vision acuity" means the ability of the human eye to see objects with clarity at close range, also termed near point acuity or near acuity.

(20) "OAEs" or "otoacoustic emission screening technology or devices" refers to a test that measures the function of the inner ear (cochlea). This technology is commonly used for screening infants and other special populations, particularly when behavioral hearing tests, such as pure tone audiometry, are not appropriate.

(21) "Optotype" means figures, numbers or letters of different sizes used in testing visual acuity.

(22) "Principal's designee" means a public health nurse, special educator, teacher or administrator designated by the school principal and responsible for supervision, training, reporting and referral of vision screening in instances where the school nurse or school principal is not filling this role.

(23) "Probe tip" means the part of an OAE screening device inserted into the ear canal to deliver sound and detect inner ear responses. It must fit snugly and comfortably for accurate screening results.

(24) "School nurse" means a registered nurse acting as the health professional in a school whose specialized practice and attendant tasks and activities advance student health, well-being and achievement; and conforms to Washington state educational and nursing laws according to chapters 18.79 RCW and 246-840 WAC, and WAC 181-79A-223.

(25) "Sloan letters" means a test using 10 specially formed letters which include C, D, H, K, N, O, R, S, V and Z to assess visual acuity.

(26) "Test-retest protocol" means a method of screening where a screener conducts two or more screenings for any student who meets the referral criteria in order to ensure the reliability of the initial screening.

(27) "Tonal stimuli" refer to sounds with a clear pitch or tone, like a musical note or a beep. These sounds are used in hearing tests to check how well someone can hear.

(28) "Visual acuity" refers to the ability of the visual system to discern fine distinctions in the environment as measured with printed or projected visual stimuli.

(1) Schools shall conduct annual screening for hearing and vision (both near and distance) for students:

(a) In kindergarten and in grades one, two, three, five, and seven; and

(b) Showing signs of possible reductions in auditory or visual acuity that may negatively impact their learning, or those referred to the district by parents, guardians, school staff, etc.

(2) If resources are available, a school may:

(a) Expand screenings to other grades;

(b) Conduct additional optional vision screenings at any grade using evidence-based screening tools and techniques; or

(c) Both expand screenings to other grades and conduct optional vision screenings as outlined in (a) and (b) of this subsection.

(1) A school shall conduct all hearing screenings using tools and procedures that are linguistically, developmentally, and age-appropriate, and shall use screening tools identified in WAC 246-760-030.

(2) A school shall conduct hearing screening according to the tool's instructions and screening protocol.

(3) A school is not required to screen a student who has already had a comprehensive audiological evaluation by a licensed professional within the last 12 months. Schools need a report or form signed by a licensed professional to waive the screening, indicating that an examination has been administered. A school must place this report or form in the student's health record.

(4) A school is not required to screen a student reported by the school district as having reduced hearing levels, as required under RCW 72.40.060.

(5) Exempt students may request to participate in hearing screenings to promote inclusion and prevent stigmatization.

(1) Schools shall use hearing screening equipment that delivers tonal stimuli at frequencies of 1,000, 2,000, and 4,000 hertz (Hz) at a sound level of 20 decibels (dB), measured at the earphones, consistent with Acoustical Society of America (ASA)/American National Standards Institute (ANSI) S3.6-2018 (R 2023) standards.

(2) Qualified persons will check the calibration of frequencies and intensity at the earphones at least once a year using equipment designed for audiometer calibration.

(3) Otoacoustic emission (OAE) screening devices may be used to screen students who cannot participate in pure tone hearing screening including, but not limited to:

(a) Students with special health care needs;

(b) Students with developmental delays or disabilities;

(c) Students who speak a language other than English;

(d) Students who are not old enough or have difficulty understanding the screener's instructions.

(4) OAE screening devices shall not replace screening using pure tone hearing screening equipment except as described in subsection (3)(a) through (d) of this section.

(5) If schools use OAE devices for students who cannot participate in pure tone hearing screening, they shall use calibrated equipment that delivers appropriate stimuli and pass/refer criteria.

(a) The tonal stimuli used during the test must be:

(i) 65/55 dB for distortion product otoacoustic emissions (DPOAEs); or

(ii) 80 dB for transient evoked otoacoustic emissions (TEOAEs).

(b) For a pass result, the screening device must show a response at least three dB louder than the background noise at a minimum of three different frequencies, ranging from 2,000 Hz to 8,000 Hz.

(1) Schools shall screen all students referenced in WAC 246-760-020 using hearing screening equipment that delivers tonal stimuli at 1,000, 2,000, and 4,000 Hz.

(2) The screener shall:

(a) Conduct screenings in an environment free of extraneous noise, to the extent possible in a school setting;

(b) Position the student so they cannot see the front of the hearing screening equipment or are not facing it;

(c) Present each tone at a hearing level of 20 dB, following ASA/ANSI 2023 standards;

(d) Reinstruct the student or reposition the earphones if they appear confused or do not respond to the tonal stimuli;

(e) If at all possible, complete screening within the first semester of each school year;

(f) Place the results of screenings, any referrals, and referral results in each student's health and/or school record; and

(g) Forward the results to the student's new school if the student transfers.

(3) If a student cannot participate in pure tone hearing screening, an OAE device may be used. For screeners using OAE devices, they shall:

(a) Examine the student's ear to select an appropriately sized probe tip that fits comfortably and securely in the ear canal;

(b) Insert the probe into the student's ear canal and begin the screening. Make sure the equipment shows that the probe is securely in place and that the student is calm and still. For the best results, the screener should help the student stay quiet and keep the probe steady during the test;

(c) Continue measuring the OAE response until the equipment shows either a "PASS" or "REFER" result.

(1) If a student does not respond to one or more frequencies in either ear during a hearing screening or gets a "refer" result from an OAE:

(a) The school must rescreen the student within six weeks, allowing a minimum of one to two weeks between screenings when possible; and

(b) The school must notify the student's teachers about the need for preferential seating in class due to the possibility of decreased hearing; and

(c) If the student's results indicate that further assessment or follow-up is needed, the school shall notify the parents or legal guardian that a comprehensive evaluation may be necessary. This evaluation may be preceded by a medical assessment to rule out other factors and to access audiology services as needed.

(d) If a school district utilizes OAE devices as part of its hearing screening procedures, the school shall identify and document the specific type of screening device used.

(2) The school shall notify parents or legal guardians if a comprehensive evaluation is needed when:

(a) The results of a hearing screening suggest it; or

(b) A school or school district does not have access to an audiologist on staff.

Each school district shall designate a district audiologist, school nurse, speech language pathologist, health assistant or other staff member to be responsible for the hearing screening program. This person must:

(1) Oversee the hearing screening program; and

(2) Have the training and experience to:

(a) Create an administrative plan for conducting annual hearing screenings and work with appropriate school staff to ensure the program is carried out efficiently and effectively;

(b) Obtain and maintain the necessary screening equipment ensuring it is calibrated correctly and in good working order; and

(c) Recruit appropriate personnel for carrying out the screening program, if assistance is necessary, and assure these personnel are sufficiently trained to:

(i) Understand the purpose and regulations of the hearing screening program; and

(ii) Use the screening equipment properly to get accurate results;

(d) Ensure screening records are created and distributed as appropriate; and

(e) Disseminate information to other school staff to familiarize them with aspects of a student's behavior that may indicate the need for referral for hearing screening.

The person designated as responsible for the hearing screening program must be sufficiently trained to meet the provisions in (c) of this subsection if they are involved in carrying out the screening program.

(1) A school shall conduct all vision screening using tools and procedures that are linguistically, developmentally and age-appropriate. For distance vision and near vision acuity screening schools shall use screening tools identified in WAC 246-760-071.

(2) A school shall conduct vision screening according to the tool's instructions and screening protocol and consistent with AAPOS and National Association of School Nurses guidance.

(3) A school is not required to screen a student who has already had a comprehensive vision examination by a licensed vision care professional within the previous twelve months. In order to waive the screening, schools need to have a report or form signed by a licensed vision care professional indicating that an examination has been administered. A school must place this report or form in the student's health record.

(4) A school is not required to screen a student who the school district has reported as having a visual impairment as required under RCW 72.40.060.

(1) A school must use the standardized optotype-based distance vision and near vision acuity screening tools approved for each grade as well as the rescreening and referral criteria by grade outlined in Table 1 of this section. When using a screening tool with a single isolated optotype or a single line of optotypes, the tool must include the use of crowding bars or crowding boxes.

(2) A school may use an instrument-based vision screening device in lieu of the optotype-based tools outlined in this section. Referral using instrument-based vision screening devices is determined through the manufacturer's criteria. If the instrument-based screening device does not generate a result for a student, a school must screen that student using the optotype-based tools outlined in this section.

(1) A school shall:

(a) Screen children with their corrective lenses on;

(b) Place the results of screening, any referrals, and referral results in each student's health record; and

(c) Forward the results to the student's new school if the student transfers.

(2) If a student meets the referral criteria set forth in WAC 246-760-071 during the first vision screening and the screening was conducted by a lay person, then the school nurse, or the school principal or his or her designee as qualified under WAC 246-760-100(4) shall rescreen the student within two weeks or as soon as possible after the original screening before referring the child to a licensed vision care professional for an assessment.

(3) If the student meets the referral criteria set forth in WAC 246-760-071 during the first vision screening, and the screening was conducted by the school nurse; the school principal or his or her designee; a volunteer who is a licensed vision care professional; or an individual trained by and conducting vision screening on behalf of a nationally recognized service organization that utilizes a test-retest protocol for vision screening, a school may either refer the student after the first screening or rescreen the student at the discretion of the school nurse, or the school principal or his or her designee.

(4) A school shall notify a child's parent or guardian with a written referral if a child meets the referral criteria set forth in WAC 246-760-071 during:

(a) The first screening if a rescreening is not required; or

(b) The second screening if a rescreening is required or is conducted at the discretion of the school nurse, or the school principal or his or designee.

(5) This written referral shall indicate that school-based vision screening is not a substitute for a comprehensive eye examination, include the screening results, and include language recommending that:

(a) The parent or guardian take the child to a licensed vision care professional to receive a comprehensive eye examination; and

(b) An appropriate remedy, such as corrective lenses, be obtained if indicated.

(6) Only the school nurse, or the school principal or his or her designee may notify a child's parent or guardian in order to refer the student for professional care. A school nurse, or school principal or his or her designee shall notify parents or guardians in writing that their child should be evaluated by a licensed vision care professional when:

(a) The student meets the referral criteria for vision screening tests conducted under WAC 246-760-071; or

(b) The school nurse, or school principal or his or her designee observes other signs or symptoms related to eye problems that negatively impact the student's learning; or

(c) The student is unable to complete vision screening for any reason.

(1) Persons performing visual screening may include, but are not limited to, school nurses, school principals, other school personnel, or lay persons who have completed training in vision screening; and ophthalmologists, optometrists, or opticians who donate their professional services to schools or school districts. If an ophthalmologist, optometrist, or optician who donates his or her services identifies a visual problem that may impact a student's learning, the vision professional shall notify the school nurse, or the school principal or his or her designee of the results of the screening in writing but may not contact the student's parents or guardians directly per RCW 28A.210.020.

(2) Screening must be performed in a manner consistent with this chapter and RCW 28A.210.020. Any person conducting vision screening must be competent to administer screening procedures as a function of their professional training and background or special training and demonstrated competence under supervision by the school nurse, or the school principal or his or her designee.

(3) A lay person shall demonstrate his or her competence at administering the screening tools including controlling for lighting or distractions that could affect the screening results.

(4) Supervision, training, reporting and referral of vision screening shall be the responsibility of the school nurse, or the school principal or his or her designee. The principal or his or her designee must demonstrate his or her competence in vision screening through supervised training by a competent school or public health nurse or licensed vision care professional, have supervisory ability and experience, and have the ability to work well with school staff and lay persons. Ideally, the person should demonstrate the ability to teach vision screening techniques and operations to others.

(5) Students in grades kindergarten through 12 may not assist with or conduct vision screening of other students in their school district, unless students are supervised and conducting screening within the scope of an advanced vocational health-related curriculum such as nursing.