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ncds_74_a
Strictly confidential

Local Authority Code Number

Local Authority Code Number

Child's Code Number

Child's Code Number
NATIONAL CHILDREN'S BUREAU
Audiogram
NATIONAL CHILD DEVELOPMENT STUDY
(1958 Cohort)
Sponsors: Institute of Child Health, University of London National Birthday Trust Fund National Foundation for Education Research in England and Wales
In Collaboration with: Society of Education Officers Society of Community Medicine Association of Directors of Eduation (Scotland)
Chairman of Consultative Committee: Professor D. V. Donnison BA
Chairmen of Steering Committee: W. D. Wall BA. Ph.D
Executive Co-Directors: Professor N. R. Butler MD. FRCP. DCH. R. Davie BA, Ph.D, DEP.ED.Psych Mrs. M. L. Kellmer Pringle B.A. Ph.D. D.Sc
Co-Directors: M. J. R. Healy BA J. M. Tanner MD. D.Sc. FRCP. FRC.Psych W. D. Wall BA., Ph.D
Senior Research Officer: K. R. Fogelman BA

Child's surname

Generic text

Christian names

Generic text

Sex

1
Boy
2
Girl

Home address

Generic text

Child's school

Generic text

Audiogram recorded at (Name of hospital or Clinic)

Generic text

Name of recorder (Block letters)

Generic text

Professional status, e.g. Doctor, qualified audiometrician, nurse, technician, other person (please specify)

Generic text

Make of audiometer

Generic text

Date of audiogram

Generic date
Please complete audiograms overleaf
RIGHT EAR Hearing loss in dB
250 500 1000 2000 4000 8000

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

10
0
10
20
30
40
50
60
70
80
90
LEFT EAR Hearing loss in dB
250 500 1000 2000 4000 8000

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

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1 - X

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1 - X

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10
0
10
20
30
40
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60
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80
90

Remarks

Generic text
This sheet, when completed should be returned to the local authority officer supervising the survey work
End

ncds_74_a

Strictly confidential
Local Authority Code Number
Local Authority Code Number
Child's Code Number
Child's Code Number
NATIONAL CHILDREN'S BUREAU
Audiogram
NATIONAL CHILD DEVELOPMENT STUDY
(1958 Cohort)
Sponsors: Institute of Child Health, University of London National Birthday Trust Fund National Foundation for Education Research in England and Wales
In Collaboration with: Society of Education Officers Society of Community Medicine Association of Directors of Eduation (Scotland)
Chairman of Consultative Committee: Professor D. V. Donnison BA
Chairmen of Steering Committee: W. D. Wall BA. Ph.D
Executive Co-Directors: Professor N. R. Butler MD. FRCP. DCH. R. Davie BA, Ph.D, DEP.ED.Psych Mrs. M. L. Kellmer Pringle B.A. Ph.D. D.Sc
Co-Directors: M. J. R. Healy BA J. M. Tanner MD. D.Sc. FRCP. FRC.Psych W. D. Wall BA., Ph.D
Senior Research Officer: K. R. Fogelman BA
Child's surname
Generic text
Christian names
Generic text
Sex
1
Boy
2
Girl
Home address
Generic text
Child's school
Generic text
Audiogram recorded at (Name of hospital or Clinic)
Generic text
Name of recorder (Block letters)
Generic text
Professional status, e.g. Doctor, qualified audiometrician, nurse, technician, other person (please specify)
Generic text
Make of audiometer
Generic text
Date of audiogram
Generic date
Please complete audiograms overleaf

RIGHT EAR Hearing loss in dB

250 500 1000 2000 4000 8000

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

1 - O

10
0
10
20
30
40
50
60
70
80
90

LEFT EAR Hearing loss in dB

250 500 1000 2000 4000 8000

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

1 - X

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10
0
10
20
30
40
50
60
70
80
90
Remarks
Generic text
This sheet, when completed should be returned to the local authority officer supervising the survey work