STATE BOARD OF HEALTH

[Filed April 22, 2025, 12:36 p.m.]

Preproposal statement of inquiry was filed as WSR 23-22-004.

Title of Rule and Other Identifying Information: Chapter 246-760 WAC, Auditory screening standards for school districts. The Washington state board of health (board) is proposing updates to hearing screening standards for schools. The changes would allow school districts to use otoacoustic emission (OAE) devices as an alternative screening tool for students who cannot participate in pure tone audiometry tests. The updates also aim to clarify the language of the rules, ensure consistency with vision screening sections of the rule, and align with current national standards.

Hearing Location(s): On June 4, 2025, at 1:30 p.m., at Washington State Department of Health, 111 Israel Road S.E., Tumwater, WA 98501, Town Center Two (TC2), Rooms 166 and 167; or virtually at https://us02web.zoom.us/webinar/register/WN_DiQ17FVFSSutIhHIzCvdRw#/registration. The board will be holding a hybrid hearing with the option to attend and testify either via Zoom or in person.

Date of Intended Adoption: June 4, 2025.

Submit Written Comments to: Molly Dinardo, P.O. Box 47990, Olympia, WA 98504-7990, email schoolauditoryscreening@sboh.wa.gov, please submit comments through AirTable at https://airtable.com/apphIxdKIbsd4Drza/pagrWs7U1SIsueuVU/form, by May 23, 2025, 11:59 p.m.

Assistance for Persons with Disabilities: Contact board staff, phone 360-236-4110, TTY 711, email wsboh@sboh.wa.gov, by May 28, 2025.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The board is proposing updates to chapter 246-760 WAC to modernize its school hearing screening standards. These changes would allow schools to use OAE devices as an optional tool for students who can't complete pure-tone audiometry. The proposal also updates the rules to align with national best practices, use more inclusive language, and improve clarity and consistency with the vision screening sections of the rule. The board anticipates these changes will make the rules easier to understand and use, and provide more options for schools to screen students who can't be screened with the current audiometry equipment permitted in rule.

Reasons Supporting Proposal: The proposed rule is essential to meet the goals and objectives of RCW 28A.210.020. It also ensures the board supports evidence-based hearing screening tools, providing consistent, quality screenings for all students across schools and districts. Early identification of hearing challenges helps ensure children receive the support they need to succeed and prevent hearing reductions from affecting their learning. The board's hearing screening standards have not been updated since 2002. This rule making is essential to align screening practices with current evidence-based standards and ensure school screening staff can access clear, up-to-date procedures. Without these updates, the hearing screening rules would be inconsistent with vision screening standards, use less clear language, and offer fewer screening options for students unable to complete pure-tone audiometry.

Statutory Authority for Adoption: RCW 28A.210.020.

Statute Being Implemented: RCW 28A.210.020.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Washington state board of health, governmental.

Name of Agency Personnel Responsible for Drafting: Molly Dinardo, 101 Israel Road S.E., Tumwater, WA 98504, 564-669-3455; Implementation and Enforcement: Office of the Superintendent of Public Instruction, 600 Washington Street S.E., Olympia, WA 98504-7200, 360-725-6000.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Molly Dinardo, P.O. Box 47990, Tumwater, WA 98504, phone 564-669-3455, TTY 711, email molly.dinardo@sboh.wa.gov.

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(3) as the rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect.

Explanation of exemptions: WAC 246-760-001, 246-760-010, 246-020 [246-760-020], 246-760-025, 246-760-050, and 246-760-060 are all exempt because the rule updates clarify rule language without changing its effect.

Scope of exemption for rule proposal:

Is partially exempt:

Explanation of partial exemptions: [No further information supplied by agency].

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The proposed rule does not impose more-than-minor costs on businesses, as this rule was determined to not incur any additional costs.

Chapter 246-760 WAC

((AUDITORY))HEARING AND ((VISUAL))VISION SCREENING STANDARDS—SCHOOL DISTRICTS

AMENDATORY SECTION(Amending WSR 17-03-009, filed 1/4/17, effective 7/1/17)

WAC 246-760-001Purpose and application of ((auditory and visual))hearing and vision screening standards for school districts.

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

AMENDATORY SECTION(Amending WSR 17-03-009, filed 1/4/17, effective 7/1/17)

WAC 246-760-010Definitions, abbreviations, and acronyms.

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.

(((3)))(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.

(((4)))(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.

(((5)))(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.

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

(((6)))(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.

(((7)))(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.

(((8)))(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.

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

(((10)))(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.

(((11)))(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.

(((12)))(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.

(((13)))(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.

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

(((15)))(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.

(((16)))(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.

AMENDATORY SECTION(Amending WSR 17-03-009, filed 1/4/17, effective 7/1/17)

WAC 246-760-020((Frequency))Screening requirements for schools ((to screen children)).

(((1) A school shall conduct auditory and distance vision and near vision acuity screening of children:

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

(b) Showing symptoms of possible loss in auditory or visual acuity and who are referred to the district by parents, guardians, school staff, or student self-report.

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

(a) Expand vision screening to any other grade;

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

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

(3) If resources permit, schools shall annually conduct auditory screening for children at other grade levels.))(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.

((AUDITORY ACUITY))HEARING SCREENING STANDARDS

WAC 246-760-025Hearing screening.

(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.

AMENDATORY SECTION(Amending WSR 02-20-079, filed 9/30/02, effective 10/31/02)

WAC 246-760-030((What are the auditory acuity screening standards for screening equipment and procedures?))Required and alternative hearing screening tools.

(1) Schools shall use ((auditory))hearing screening equipment ((providing))that delivers tonal stimuli at frequencies ((at one thousand, two thousand, and four thousand herz))of 1,000, 2,000, and 4,000 hertz (Hz) at ((hearing))a sound level((s)) of ((twenty))20 decibels (dB), ((as)) measured at the earphones, ((in reference to))consistent with Acoustical Society of America (ASA)/American National Standards Institute (ANSI) ((1996))S3.6-2018 (R 2023) standards.

(2) Qualified persons will check the calibration of frequencies and intensity at the earphones at least ((every twelve months, at the earphones,))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;

(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 transitory 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.

AMENDATORY SECTION(Amending WSR 02-20-079, filed 9/30/02, effective 10/31/02)

WAC 246-760-040((What are the procedures for auditory acuity screening?))Hearing screening procedures.

(1) Schools shall screen all ((children))students referenced in WAC 246-760-020 ((on an individual basis at one thousand, two thousand, and four thousand))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;

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

(c) Present each ((of the tonal stimuli))tone at a hearing level of ((twenty))20 dB ((based on the)), following ASA/ANSI ((1996))2023 standards;

(((b) Conduct screenings in an environment free of extraneous noise;

(c)))(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;

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

(((e)))(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;

AMENDATORY SECTION(Amending WSR 02-20-079, filed 9/30/02, effective 10/31/02)

WAC 246-760-050((What are the auditory acuity))Hearing screening referral procedures((?)).

(1) If a ((child))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 ((child))student within six weeks, allowing a minimum of one to two weeks between screenings when possible; and

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

(c) If the student's results indicate the need for additional assessment or follow-up, the school shall notify the parents or legal guardian ((of the need for audiological evaluation if the student fails the second screening))that a comprehensive audiological assessment is necessary.

(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((s)) shall notify parents or legal guardians((of the need for))if a medical evaluation is needed if:

(a) ((Indicated by audiological evaluation))The results of a hearing screening suggest it; or

(b) ((A))An audiological evaluation is ((not available))unavailable.

AMENDATORY SECTION(Amending WSR 02-20-079, filed 9/30/02, effective 10/31/02)

WAC 246-760-060((What are the auditory acuity))Hearing screening ((qualifications for)) personnel((?))qualifications.

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

(1) ((Responsibility for administering the auditory))Oversee the hearing screening program; and

(2) Have the training and experience to:

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

(b) Obtain and maintain the necessary ((instrumentation for carrying out the screening program, and))screening equipment ensuring ((the equipment))it is calibrated correctly and in ((proper))good working order ((and calibration)); and

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

(i) Understand the purpose((s)) and regulations ((involved in))of the ((auditory))hearing screening program((s)); and

(ii) ((Utilize))Use the screening equipment ((to ensure maximum accuracy))properly to get accurate results;

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

(e) Disseminate information to other school ((personnel familiarizing))staff to familiarize them with aspects of a ((child's))student's behavior ((indicating))that may indicate the need for referral for ((auditory))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.

((VISUAL ACUITY))VISION SCREENING STANDARDS

AMENDATORY SECTION(Amending WSR 17-03-009, filed 1/4/17, effective 7/1/17)

WAC 246-760-100Qualifications for ((the visual acuity))vision screening personnel.

(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 ((twelve))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.