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  1. Student Name
  2. Social Security Number
  3. Date of birth
  4. Date of evaluation
  5. Diagnosis
  6. Indicate level of severity and pertinent history
  7. Describe assessment procedures used (attach audiogram or other  appropriate test results).
  8. Is the loss in hearing stable or progressive? Describe and include  prognosis.
  9. Does the student use assistive devices such as hearing aids, FM  systems, or Cochlear implants?
  10. Describe how the student benefits from these devices.
  11. Describe the student’s ability to use oral and written language.
  12. Describe the student’s primary mode of communication.
  13. What are your recommendations regarding academic accommodations for this student?
  14. Name, signature, and title of evaluator
  15. Date