TITLE 25. HEALTH SERVICES
PART 1. DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 37. MATERNAL AND INFANT HEALTH SERVICES
SUBCHAPTER
C.
The executive commissioner of the Texas Health and Human Services Commission (HHSC), on behalf of the Department of State Health Services (DSHS), adopts amendments to §37.21, concerning Purpose; §37.22, concerning Definitions; §37.23, concerning Vision Screening; §37.24, concerning Hearing Screening; §37.25, concerning Facility Requirements; Department Activities; §37.26, concerning Recordkeeping and Reporting; §37.27, concerning Standards and Requirements for Screening Certification and Instructor Training; and §37.28, concerning Hearing Screening Equipment Standards and Requirements.
Sections 37.22, 37.23, 37.24, 37.25, 37.26, 37.27, and 37.28 are adopted with changes to the proposed text as published in the October 10, 2025, issue of the Texas Register (50 TexReg 6639). These rules will be republished. Section 37.21 is adopted without changes to the proposed text as published in the October 10, 2025, issue of the Texas Register (50 TexReg 6639). This rule will not be republished.
BACKGROUND AND JUSTIFICATION
The amendments are necessary to comply with House Bill (HB) 1297, 88th Regular Session, 2023, by Dutton which allows electronic eye charts for childhood vision screenings in public and private schools, licensed childcare centers, and licensed childcare homes. HB 1297 defines electronic eye charts and permits use for visual acuity screenings. Amendments include defining the term in §37.22(11) and permitting its use in §37.23(a)(1)(A).
The amendments also included edits to improve clarity and readability, defined terms, added training materials and referral requirements, removed unnecessary procedural details and a photoscreener training requirement, required facilities and certificate holders to comply with the program's policy and procedures manuals, added an optional hearing screen for children with disabilities or for those who do not pass initial hearing screenings, clarified who may become a certified screener or external instructor, ended audiometer registration because DSHS neither monitors nor enforces registrations, and gave facilities more control over vision screening.
Additionally, nursing program faculty and students, medical offices, and Texas Health Steps Representatives will no longer be trained and certified as screeners or external instructors.
COMMENTS
The 31-day comment period ended November 10, 2025.
During this period, DSHS received 93 stakeholder responses with a total of 362 comments regarding the proposed rules. DSHS received comments from Texas School Nurses Organization (TSNO), Texas Medical Association (TMA), American Association for Pediatric Ophthalmology and Strabismus (AAPOS), The Texas Council of Administrators of Special Education (TCASE), The University of Houston College of Optometry (UHCO), University of Houston Communication Sciences and Disorders Department, Rebion, Good-Lite, LaChance School Health Strategies LLC, Pinewoods Screening Services, and Region 4 Education Service Center. DSHS also received comments from staff of three schools, 42 school districts, and five individuals. A summary of comments relating to the rules and DSHS's responses is below.
Screening Required Within the First 120 Days of School Enrollment
Comment: Multiple commenters suggested changing §37.25(a)(1) - (3) from requiring to recommending all children due for screening be screened within the first 120 days of enrollment. Commenters stated school nurses have multiple competing priorities at the beginning of the school year and many school districts face nursing shortages.
Response: DSHS agrees with the commenters. The requirements were updated to allow flexibility in §37.25(a)(1) - (3).
Comment: Multiple commenters also suggested changing the timeframes in §37.25(a)(1) - (3) from "within the first 120 calendar days of enrollment" to "within the first 120 calendar days of attendance" because enrollment may begin as early as 30-90 days before the start of school, resulting in schools not having a full 120 calendar days to screen.
Response: DSHS agrees with the comments. The timeframes in §37.25(a) (1), (2), and (3) were changed to be based on the first day of attendance and not enrollment.
Audiometers
Comment: Multiple commenters disagreed with the proposed requirement for hearing screeners to conduct biological calibrations on audiometers the day of screening in addition to monthly biological calibrations. Commenters stated additional calibrations were time-consuming, unnecessary, and impractical because often the screener is not the person responsible for biological calibrations.
Response: DSHS agrees and modified §37.28(e) and added subsection (f) to recommend a brief pre-screen operational check to test the headset.
Comment: One commenter requested clarification on the differences between the audiometer calibration documentation in §37.28(d) which requires qualified technicians to perform annual electronic calibrations and complete exhaustive electronic calibration and (f) which requires monthly biological calibration checks performed by the audiometer owner.
Response: DSHS disagrees that clarification is needed and made no changes based on this comment. The two sets of documentation are different. Proof of the annual professional calibration should always be with the audiometer and the monthly calibration records may be stored elsewhere.
Comment: A commenter requested DSHS specify the audiometers referred to in this subchapter are screening audiometers which are different from diagnostic audiometers. Diagnostic audiometers should not be used for screening purposes. The commenter recommended audiometers be defined in this subchapter as "A device used to assess hearing sensitivity. For the purposes of this subchapter, the term refers specifically to a screening pure-tone audiometer used to conduct hearing screenings at prescribed intensity levels to identify individuals who may require further evaluation. Diagnostic audiometers are reserved for use by licensed audiologists to conduct comprehensive hearing assessments and are not permitted for screening purposes."
Response: DSHS agrees and modified §37.22(4) as recommended.
Licensed Professionals and Facilities
Comment: Multiple commenters stated school nurses should be included as licensed professionals as defined in §37.22(17) and therefore be exempt from DSHS vision and hearing certification because of nurses' educational background. Some commenters also suggested using a different term from "licensed professional" since nurses are licensed professionals.
Response: DSHS disagrees with the commenters about exempting school nurses from screener training. It is beneficial to school nurses to receive refresher training on the auditory and visual systems. School nurses must also be trained in screening procedures, recordkeeping, and reporting. Therefore, screening training and certification are warranted.
DSHS agrees with commenters that the term "licensed professional" is confusing in this subchapter. DSHS removed §37.22(17) Licensed Professional and replaced it with §37.22(23) Provider, as defined in Health and Safety Code §36.003(5).
Comment: Multiple commenters disagreed with §37.27(a)(2) which stated DSHS rules are not intended for medical offices and nursing programs. The commenters felt medical office staff should be held to the same training standards as schools and licensed childcare centers. Commenters shared medical offices are often where children who fail a screen are referred to and should therefore have at least the same level of training as school and licensed childcare screeners. Multiple commenters shared school nurses have the same educational background as medical office nurses and a higher level of education than medical assistants who are often the medical office staff member who screens.
Response: DSHS disagrees. Health and Safety Code §36.004 requires children who attend private or public preschools or schools to be screened. DSHS's responsibility is to create and implement screening rules for those locations. While it is important for medical office staff to learn to screen for vision and hearing problems, they do not require DSHS certification.
Comment: Multiple commenters requested school districts be added to the definition of facility because the reporting requirements state each facility should submit a screening report to DSHS. Historically screening reports have been reported to DSHS at the district level.
Response: DSHS disagrees with adding school districts to the definition of facility but revised §37.26(b)(6) to allow DSHS to require either facility or school district reports. The rule was further modified to allow school districts to submit either type of report. If facility reports are required, school districts may decide if the district will submit the facility reports or if it will have each facility submit its own. For the 2025-2026 school year, reporting will continue by district. If there is a change in the future to facility-level reporting, stakeholders will be given advance notice.
External Instructors
Comment: Multiple commenters disagreed with the external instructor (EI) certificate changing from five years to two. Commenters said it would be an additional time burden on nurses that are EIs in school districts that pay for substitute nurses during training. Multiple commenters said with all the current EI oversight there is no reason to shorten the certificate period to maintain quality training.
Response: DSHS agrees. The EI certificate will remain valid for five years.
Comment: Multiple commenters asked DSHS to train more EIs. Commenters stated they need more EIs to meet training demands in their school districts and to keep staff on campus or nearby for training instead of sending them off-campus for one to two days. In addition to the loss of nursing coverage during training days, school districts must also pay for substitute nurses if any are available. Multiple commenters stated additional EI training priority should not be given to larger districts because even small and medium-sized districts need additional EIs.
Response: DSHS agrees and revised §37.27(c) to reduce school districts' barriers to having an adequate number of certified screeners.
Comment: Multiple commenters stated concerns about certain EI requirements or restrictions. Commenters requested EIs not be required to teach at least one basic vision and hearing screener training and recertification training for vision and hearing each year to maintain their EI certificate. Commenters requested electronic submission of training information and an end to the 15-day advance training notice approval so training can be more flexible. A commenter requested EIs be allowed to train and certify screeners outside their own school districts to assist other districts if needed. A commenter also expressed confusion over the proposed annual training requirement, having a window of 18 months to complete.
Response: DSHS agrees and revised §37.27(c) to reduce the annual minimum training requirement and end the 15-day advance training notice. DSHS will develop a process for electronic submission of EI training records. DSHS will also allow EIs to train screeners in any other facility or school district. To reduce confusion about certificate deadlines and expiration dates, §37.27(b)(4) and §37.27(c)(3) were changed so the expiration dates for both screeners and for EIs are current for exactly five years and expire five years from the date of issue and the 18-month window for the annual minimum training requirement for EIs was removed.
Record Keeping and Reports
Comment: One commenter requested a language update to clearly state electronic signatures are allowed on electronic student records.
Response: DSHS disagrees. It is implied that an electronic signature is accepted in an electronic health record and not text that needs to be added to an agency rule.
Comment: One commenter requested the time limit a screener has before submitting screening records to a facility be extended from the proposed three business days to seven.
Response: DSHS disagrees. Three business days to submit screening data to a facility is sufficient.
Technology
Comment: Multiple commenters want to use photoscreeners and other automated screening devices for children of all ages. Some ask specifically to use automated screening devices as the sole means of vision screening. Reasons provided include ease of use, consistency, and ability to identify signs of multiple vision disorders.
Response: DSHS agrees. While visual acuity screening with an eye chart is the gold standard for childhood vision screening, DSHS understands school districts and other facilities want more options for vision screening. DSHS added §37.23(a)(1) allowing facilities to choose the screening modality they use and §37.23(a)(2)(B) and §37.23(a)(3)(B) to clarify referral criteria for children ages four and younger or five and older, respectively.
Comment: Two commenters recommended DSHS embrace vision screening modalities that involve game-like interactions. The commenters stated such interactions are standard practice in pediatric ophthalmology and should not be looked at as detracting from the screening process.
Response: DSHS agrees with the commenters and appreciates their expert feedback. DSHS modified §37.23(a)(1) to allow automated screening devices for all ages. This change allows facilities to embrace technology for vision screening, including interactive modalities. Note definition of "electronic eye chart" in §37.22(11) does not include automated computer programs that assess an individual's visual acuity through the individual's interaction with the program by playing a game. Automated screening devices, however, do not have the restriction.
Comment: A commenter requested that §37.23(5) exchange "photoscreener" with "instrument-based screener" because it is the more inclusive term.
Response: DSHS agrees and made the change and defined "instrument-based vision screener" in §37.22(16).
Comment: A commenter stated purchasing electronic eye charts could pose a financial burden for some schools and school districts.
Response: DSHS disagrees. Facilities are not required to purchase electronic eye charts.
Comment: Multiple commenters recommend DSHS create standards and guidelines for automated screening devices. The commenters state facilities must only use devices that are peer-reviewed and evidence-based. Other commenters asked DSHS to test and vet automated screening devices or to have a panel do test screening devices.
Response: DSHS agrees standards and guidelines for automated screening devices are important for quality and consistency statewide and will include them in the vision screening manual. It is outside DSHS's scope to test and vet automated screening devices and DSHS does not recommend specific products.
Comment: A commenter recommended §37.27(b)(2) and (b)(3) "needs" be replaced with "requires" for screener certification for photoscreener users.
Response: DSHS agrees and made the change and also replaced "photoscreener" with "instrument-based vision screening device" because it is a broader term.
Miscellaneous
Comment: One commenter stated HB 2789 (89th Texas Regular Session, 2025) misled some licensed childcare centers and licensed childcare homes to believe they no longer needed to screen children and maintain screening records.
Response: DSHS agrees and will communicate with licensed childcare centers and licensed childcare homes to make sure they understand vision and hearing screens are still required.
Comment: Multiple commenters pointed out that §37.25(a)(4) did not list students in pre-k, kindergarten, or first grade as exempt from screening if a family provides a record showing a professional examination was conducted during the current grade year or in the previous one.
Response: DSHS agrees with the commenters. DSHS removed this provision to conform with existing law found in Education Code Section 26.0083 that requires parental consent for health-related services such as vision and hearing screening effective September 1, 2025.
Comment: One commenter wants DSHS to provide clearer protocols for children with special health care needs because the commenter feels it is redundant to refer them every year.
Response: DSHS disagrees. The rules allow alternative screening methods for children with special health care needs. If a screen cannot be performed at the facility, the child should be referred.
Comment: One commenter expressed that schools have a difficult time getting parents to complete a referral regardless of how many support services are provided.
Response: DSHS agrees this is a challenge for schools. Schools should continue to try to get parents to complete a referral and document the school's efforts.
Comment: One commenter recommends DSHS add to the definition of "professional examination" to differentiate it from "screening."
Response: DSHS disagrees that the definitions need additional differentiation and did not change them. As defined in §37.22(21) and (26) respectively, a professional examination is diagnostic, while a screening is an evaluation to see if an individual needs a professional examination and diagnosis.
Comment: One commenter recommended DSHS add "or a DSHS-certified instructor" to §37.22(25) to make it clear a screener can be certified by DSHS or by a DSHS-certified external instructor.
Response: DSHS agrees and made the change.
Comment: Two commenters noted that "test" and "screen" are both used and said that if they are interchangeable, one of the terms should be dropped for consistency.
Response: DSHS agrees. "Screen" is usually the appropriate term in this subchapter. All inaccurate uses of "test" were removed or replaced. The definitions of audiometric testing device, testing equipment, and tests were removed from proposed §37.22(6), §37.22(31), and §37.22(32), respectively. The paragraphs were renumbered accordingly.
Comment: One commenter recommended removing "find specific vision disorders" from §37.23(a) because it implies diagnosis.
Response: DSHS agrees and made the change.
Comment: One commenter worried §37.23(a)(5) as written implies photoscreening is required. The commenter requested "when applicable" be replaced with "when available" because not all facilities have access to photoscreeners.
Response: DSHS agrees and made the change.
Comment: One commenter pointed out a grammatical error in §37.23(d) and said it should be changed from "a individual" to "an individual".
Response: DSHS agrees but removed §37.23(d) to conform with existing law found in Education Code Section 26.0083 that requires parental consent for health-related services such as vision and hearing screening effective September 1, 2025. Therefore, no correction is necessary.
Comment: One commenter requested DSHS change §37.24(a)(3), from rescreening in "28 calendar days" to "within 31 calendar days" because it is easier to keep up with.
Response: DSHS agrees and made the change.
Comment: Two commenters told DSHS §37.24(a)(4) and (5) should state more clearly if a child does not respond to any one of three frequencies at 25dB or lower in the second sweep check they should be referred, and that if a child does not respond at 25 dB or lower for frequencies of 1,000, 2,000, and 4,000 Hz during an extended recheck, they should be referred.
Response: DSHS agrees and made the changes.
Comment: Two commenters asked about §37.25(b) which states facilities may admit a child temporarily for up to 60 calendar days or may deny admission until the screening record is provided if a parent or guardian has the child screened somewhere else. One commenter makes the point a school administrator should not be allowed to withhold a child's admission because keeping the child out of school is more harmful than the child not being screened. The other commenter asked if administrators are allowed to exclude a child from school and highlighted administrative and budgetary consequences.
Response: DSHS disagrees but removed this provision to conform with existing Education Code Section 26.0083 that requires parental consent for health-related services such as vision and hearing screening effective September 1, 2025.
Comment: One commenter requests DSHS remove statements throughout the rules informing stakeholders the vision, hearing, and external instructor manuals contain additional information and facilities and certificate holders must follow them. The commenter worries this is a way for DSHS to add new requirements without the level of public oversight afforded by the rules amendment process.
Response: DSHS understands the stakeholder's concern. The manual is designed to explain the rules in greater detail. Stakeholders are encouraged to notify the program if there is content in the manual that contradicts the rules or has no basis in rule. That is not the program's intent, and the program will resolve it.
Comment: Two commenters asked for clarification on §37.24(e) regarding the exemption for students who are under active or ongoing medical care for hearing condition. Clarification was requested regarding the validity period of supporting documentation. For example, if a student has had a cochlear implant for three years and has provider documentation from three years ago indicating they are under ongoing medical management--and the parent confirms the student remains under such care--does that original provider's note remain valid? Is it necessary for parents to obtain updated provider documentation each school year to verify continued medical oversight for students requiring long-term hearing management?
Response: DSHS agrees and removed this provision to conform with existing law found in Education Code Section 26.0083 that requires parental consent for health-related services such as vision and hearing screening effective September 1, 2025.
Comment: One commenter recommended DSHS remove §37.25(g) regarding external instructors from its current section and move it to §37.27 which includes all other external instructor information and requirements. The commenter felt it was misplaced.
Response: DSHS agrees and made the change.
Comment: One commenter recommended changing §37.26(b)(6)(A) from "showing a disorder was screened for" to "showing a disorder was present" because the relevant information is whether the presence of a disorder was identified.
Response: DSHS agrees and made the change.
Comment: A commenter recommended deleting §37.27(a)(3) because the early mention of external instructors is unnecessary. The process to become an external instructor is listed in detail in §37.27(c).
Response: DSHS agrees and deleted §37.27(a)(3).
Comment: A commenter recommended DSHS replace "regular" with "annual" in reference to exhaustive electronic calibrations in §37.28(d) because "annual" is an objective measure of frequency.
Response: DSHS agrees and made the change.
Additional Changes
DSHS simplified certificate expiration dates for certified screeners by removing extensions to the end of the calendar year of expiration. Certificates will now expire five years from the date of issue for both certified screeners and certified external instructors.
DSHS included §37.22(6) to define the term automated vision screening devices because it is used within the rules.
DSHS modified §37.23(a), §37.24(a), and §37.25(a) and removed §37.24(c), §37.25(a)(4), §37.25(b), and §37.25(c) to conform with existing law found in Education Code Section 26.0083 that requires parental consent for health-related services such as vision and hearing screening effective September 1, 2025.
DSHS removed proposed §37.27(c)(1)(C) to reduce barriers to becoming a DSHS-certified external instructor. The subparagraphs were renumbered accordingly.
DSHS added §37.27(c)(14) to clarify that DSHS will not recognize and certify a screener trained by a former DSHS-certified external instructor with a revoked certificate.
STATUTORY AUTHORITY
The amendments are adopted under Texas Government Code §524.0151 and Texas Health and Safety Code §1001.075, which authorize the executive commissioner of HHSC to adopt rules for the operation and provision of health and human services by DSHS and for the administration of Texas Health and Safety Code Chapter 36.
§37.22.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.
(1) American Academy of Pediatrics (AAP)--A professional organization that makes health recommendations for children.
(2) American Association for Pediatric Ophthalmology and Strabismus (AAPOS)--A professional organization that, along with the AAP, sets recommended vision screening standards. AAPOS works to improve children's eye care, supports the training of pediatric eye doctors, supports pediatric eye research, and helps adults with alignment issues.
(3) American National Standards Institute, Inc. (ANSI)--A national organization that provides information about standards used in the United States and around the world.
(4) Audiometer--A device used to evaluate hearing sensitivity. For the purposes of this subchapter, the term refers specifically to a screening pure-tone audiometer used to conduct hearing screenings at prescribed intensity levels to identify individuals who may require further evaluation. Diagnostic audiometers are reserved for use by licensed audiologists to conduct comprehensive hearing assessments and are not permitted for screening purposes.
(5) Audiometric calibration equipment--Electronic devices used to adjust audiometers.
(6) Automated vision screening device--A vision screening instrument that uses automation technology (like computer control systems, software, etc.,) to perform vision screening tasks with little or no direct human intervention for each individual sample or patient.
(7) Biological calibration check--A method to check an audiometer's accuracy by evaluating the device on an individual with known hearing levels.
(8) Calibration--The process of comparing an instrument or device to a standard and making adjustments to an acceptable level of accuracy.
(9) Certificate--A qualification given to individuals who complete vision or hearing screener training provided by either the Department of State Health Services (DSHS) or a DSHS-certified instructor.
(10) dB--The decibel is a unit for measuring the loudness of sounds. Decibels range from zero, which is the quietest sound an average person can hear, up to around 130, which is the average level of sound that causes pain.
(11) Electronic eye chart--Any computerized or other electronic system, device, or method of displaying on an electronic screen medically accepted and properly sized optotypes, which may be letters, numbers, or symbols a health care practitioner or other person uses to assess an individual's visual acuity. The term does not include an automated computer program that assesses an individual's visual acuity through the individual's interaction with the program by playing a game.
(12) Exhaustive calibration--An audiometer calibration that checks all settings for both earphones.
(13) Extended recheck--A hearing screen used after a child has failed two sweep-check screens.
(14) Facility--Includes public and private preschools and schools, defined as follows:
(A) schools, as defined in Texas Health and Safety Code §36.003;
(B) preschools, as defined in Texas Health and Safety Code §36.003;
(C) child care centers licensed by the Health and Human Services Commission (HHSC); and
(D) child care homes licensed by HHSC.
(15) Hz--Hertz is a unit of frequency equal to one cycle per second.
(16) Instrument-based vision screeners--A broad term for any vision screening tool used for precise measurement, monitoring, or recording of visual information. Automated devices like photoscreeners and autorefractors that estimate refractive errors and other factors that may cause vision problems in children are types of instrument-based vision screeners.
(17) Optotype--A standardized figure or letter used to evaluate visual acuity.
(18) Otoacoustic emissions (OAE) testing--A hearing screen that checks vibrations from the inner ear using sounds from a small device placed in the ear. OAE is an alternate screening method for children with intellectual or developmental disabilities.
(19) Pass/Fail--Allowable documentation of results if photoscreening is used for vision screening, as outlined in this subchapter.
(20) Photoscreener--A device that uses a special camera to check a child's vision using light reflexes to identify vision problem risk factors.
(21) Professional examination--A diagnostic evaluation by a provider with expertise to address the diagnostic needs of an individual with possible vision or hearing issues. This examination meets the requirements of this subchapter and Texas Health and Safety Code Chapter 36.
(22) Program--DSHS Vision and Hearing Screening Program.
(23) Provider--A person who delivers remedial services to individuals who have special senses and communication disorders, including a physician, audiologist, speech pathologist, optometrist, or psychologist. The term provider used here also includes locations such as a hospital, clinic, rehabilitation center, university, or medical school.
(24) Reporting year--A 12-month period beginning June 1 of each year and ending May 31 of the next year.
(25) Screener--An individual conducting vision or hearing screenings. A screener is either a provider as defined in this subchapter or is trained and certified by DSHS or a DSHS-certified external vision or hearing instructor to conduct vision or hearing screenings, or both.
(26) Screening--An evaluation to see if someone might need a professional examination.
(27) Screening equipment--An instrument or device used to measure sensory abilities.
(28) Sweep-check--A hearing screen using a pure-tone audiometer to check if an individual can hear tones at 1000 Hz, 2000 Hz, and 4000 Hz at 25 dB.
(29) Telebinocular instrument--A device used to check for various eye defects and measure visual acuity.
(30) Vision disorder--An impairment of the sense of vision.
(31) Visual acuity--The ability to distinguish letters or symbols at 20 feet or with a chart that simulates 20 feet. In this subchapter, visual acuity specifically means how clearly an individual can see things far away, measured as a standard ratio like 20/20.
§37.23.
(a) Once the individual's parent or guardian has given consent for screening, vision screening is required to find signs of potential vision disorders for individuals attending a facility. Vision screening as described in this subchapter must meet the following requirements.
(1) Facilities and school districts may select subparagraph (A) or (B) of this paragraph for vision screening of all ages. Deciding factors may include student population, screener availability, and cost.
(A) Facilities may screen for visual acuity using traditional wall charts or electronic eye charts that show approved optotypes at the correct distances. See the vision screening manual on the Department of State Health Services (DSHS) website for detailed instructions and a list of approved optotypes.
(B) Facilities may screen using an automated screening device. Refer to the vision screening manual on the DSHS website for additional guidance.
(C) Facilities must calibrate, operate, and maintain all screening devices or equipment according to the manufacturer's instructions. Any screening tool that is not in good working order must not be used. The screening tool must be repaired or replaced.
(2) Facilities must refer children aged four years and younger for a professional examination in the following circumstances.
(A) Either eye cannot correctly identify the majority of optotypes on the 20/40 acuity line or if there is a difference of two lines between passing acuities in either eye. For example, if a child has 20/40 vision in one eye and 20/20 in the other, the child must be referred. However, if a child has 20/40 vision in one eye and 20/30 in the other, the child passed the screening.
(B) Either eye receives a failing result when screened with an automated screening device. DSHS recommends children who fail an automated screen receive a follow-up screen with a traditional or electronic eye chart and other optional screening methods described in the vision screening manual on the DSHS website.
(3) Facilities must refer children aged five years and older for a professional examination in the following circumstances.
(A) Either eye cannot correctly identify the majority of optotypes on the 20/30 line. The DSHS requirement differs from the AAPOS standard of 20/32.
(B) Either eye receives a failing result when screened with an automated screening device. DSHS recommends children who fail an automated screen receive a follow-up screen with a traditional or electronic eye chart and other optional screening methods described in the vision screening manual on the DSHS website.
(4) Facilities must refer to and comply with additional pass or fail criteria in the vision screening manual on the DSHS website.
(5) Facilities must use instrument-based vision screening, when available, for children aged 42 months to five years, as recommended by AAPOS, and for individuals with disabilities who do not respond well to other screening methods. Refer a child for a professional examination if the child fails the photoscreening.
(b) A screener who is not a provider and conducts vision screening in facilities must be trained and certified as described in §37.27 of this subchapter (relating to Standards and Requirements for Screening Certification and Instructor Training).
(c) Facilities must give the child's parent, other legally responsible adult, or the individual in the scenarios described in Texas Family Code §32.003, a referral form if the child fails a second screening or if after failing the initial screening, the screener determines a second screening is unnecessary. The referral is for further evaluation by an appropriate provider. Facilities must not refer a child to a specific person.
(d) Facilities, school districts, and screeners must follow all instructions in the vision screening manual available on the DSHS website.
§37.24.
(a) Once the individual's parent or guardian has given consent for screening, hearing screenings to detect hearing disorders must be provided for individuals attending a facility. Hearing screening as described in this subchapter must meet the following requirements.
(1) Use a pure-tone audiometer to perform a sweep-check screen.
(2) Record the screening results for each ear at less than or equal to 25 dB for 1000 Hz, 2000 Hz, and 4000 Hz.
(3) A screener must perform a second sweep-check screen if the results show that the child did not respond to any one of the three frequencies in either ear. If the child has a cold, congestion, fluid buildup in the ears, or any other condition impacting hearing, delay the second sweep-check screen. The screener must perform the rescreening no later than 31 calendar days after the initial screening.
(4) A screener must either perform an optional extended recheck or refer the child for a professional examination if the child does not respond to any one of the three frequencies in either ear on the second sweep-check. The hearing screening manual lists the steps for conducting an extended recheck.
(5) A screener must refer for a professional examination if the child does not respond to any one of the three frequencies in either ear at 25 dB or lower during an extended recheck. The hearing screening manual lists the steps for conducting an extended recheck.
(b) Otoacoustic emissions (OAE) testing may replace pure-tone audiometry only if a child has a documented disability preventing audiometer screening. OAE testing is optional and dependent on the screener's access to OAE testing equipment. The screener must use the equipment according to the manufacturer's recommendations.
(c) A screener who is not a provider and performs hearing screenings in facilities must be trained and certified as described in §37.27 of this subchapter (relating to Standards and Requirements for Screening Certification and Instructor Training).
(d) Facilities must give the child's parent, other legally responsible adult, or the individual in the scenarios described in Texas Family Code §32.003, a referral form if the child fails a second sweep-check or extended recheck screening. The referral is for further evaluation by an appropriate provider. Facilities must not refer a child to a specific person.
(e) Facilities, school districts, and screeners must follow all instructions in the hearing screening manual available on the Department of State Health Services (DSHS) website.
§37.25.
(a) The chief administrator must ensure that each individual admitted to the facility is screened according to these screening requirements, provided the individual's parent or guardian has given consent for screening.
(1) Children ages four and older as of September 1 of the school year who are enrolled in any facility for the first time must have vision and hearing screens. The screens should occur within 120 calendar days of the first attendance day. If a child enrolls within 60 calendar days of the end of the school year, the child's vision and hearing must be screened the next school year and should occur within 120 calendar days of the first attendance day.
(2) Children in pre-kindergarten and kindergarten must be screened each year. Screens should occur within 120 calendar days of the first attendance day.
(3) Children in the first, third, fifth, and seventh grades must be screened for vision and hearing problems. Screens should occur within 120 calendar days of the first attendance day in each of those grades to allow for early intervention if a problem is found.
(4) Children turning four years old after September 1 of the school year do not need to be screened until the next school year.
(5) Children may be screened on an alternate schedule (i.e., pre-kindergarten, kindergarten, first, second, fourth, and sixth grades) if DSHS approves a written request. DSHS may set conditions so children receive necessary screenings during the transition.
(b) The facility must verify the screener has a valid DSHS screening certificate before screening begins.
(c) Volunteers must have a high school diploma or equivalent to help with vision and hearing screenings. The screener is responsible for deciding how a volunteer will assist with the screening process, consistent with all state and federal confidentiality requirements.
(d) Facilities must follow DSHS rules, instructions, policies, and the vision and hearing screening manuals available on the DSHS website.
§37.26.
(a) Screeners at facilities must follow the rules for keeping records and reporting information.
(1) A screener must document in each child's screening record the specific screening performed, the date the screening was performed, observations made during the screening, and results. The screener must document the child's name, age or birthdate, and if the child is wearing corrective lenses during the vision screening. The screener must sign and date this information.
(2) A screener must provide facilities a copy of the screener's Department of State Health Services (DSHS) screener certificate.
(3) Screeners at a facility must submit the required documentation referenced in paragraph (1) of this subsection to the facility by the specified deadline or no later than three business days after the screening.
(b) Facilities must follow the rules for keeping records and reporting information.
(1) A facility must maintain vision and hearing screening records onsite for at least two years.
(2) A facility must maintain records of screening exemptions found in this subchapter for at least two years.
(3) A facility must maintain the records received from screeners for at least two years.
(4) A child's screening records may be transferred between facilities without consent of the child's parent, managing conservator, or legal guardian, or the individual in the scenarios described in Texas Family Code §32.003, according to Texas Health and Safety Code §36.006(c).
(5) Facilities must provide the required records to DSHS in a timely manner if requested. DSHS or its representatives may enter a facility and inspect vision and hearing screening records.
(6) Facilities or school districts must submit a yearly report on the vision and hearing screening status of the aggregate population screened during the reporting year. The report must be submitted on or before June 30 of each year in the manner specified by DSHS at https://www.dshs.texas.gov/vision-hearing-screening. DSHS may require individual reports for each school or may accept a single report from the school district. DSHS will notify stakeholders of the reporting requirement on the program website. If individual reports are required, school districts will determine if either the district will submit individual facility reports or will have each facility submit a report.
(A) Hearing screening--The total number of children screened, including the number who failed; the number screened by OAE testing; the number referred for professional examination; the number who left the facility before the facility received the professional examination results; professional examination results showing none of the screened disorders were present; professional examination results showing a disorder was present; and referrals for a professional examination where no professional examination was done.
(B) Vision screening--The total number of children screened, including the number screened with glasses or contact lenses, the number screened with instrument-based vision screeners, and the number screened with a wall or electronic eye chart; the number who failed; the number referred for professional examination; the number who left the facility before the facility received the professional examination results; the number whose professional examination results indicated no issues; the number whose professional examination results indicated an issue; and the number referred for a professional examination where no examination was done.
(c) Additional recordkeeping requirements for screeners who own or use audiometers and audiometric screening equipment are in §37.28(g) of this subchapter (relating to Hearing Screening Equipment Standards and Requirements).
(d) Submit documents described in this subchapter as directed on the DSHS website.
(e) Facilities, school districts, and screeners must follow all recordkeeping instructions in the vision and hearing screening manuals.
§37.27.
(a) A screener working in a facility must be certified by the Department of State Health Services (DSHS) unless the screener is a provider. Training for screeners is provided either directly by DSHS or by instructors authorized by DSHS to issue certificates. There is no fee for taking the course in either case.
(1) DSHS provides training and issues certificates when the course is completed. To join, participants must have a high school diploma or equivalent and sign a form at the start of the course. Individuals who finish the training and pass the tests will receive a certificate from DSHS to conduct screenings.
(2) The training and certification described in this subchapter are not intended for staff in medical offices or students in medical, nursing, or other training programs. Individuals who do not screen children in facilities as defined in this subchapter are neither eligible nor required to be trained and certified by DSHS.
(b) Holders of certificates issued as described in this section must follow these requirements.
(1) Certificate holders may conduct the type of screening listed on the certificate. Certificate holders must follow all the rules in this subchapter, and failure to do so may lead to modifications, suspension, or cancellation of the certificate.
(2) If a screener uses an instrument-based vision screening device, the screener must follow the manufacturer's instructions. The screener also requires a current DSHS screening certificate as described in subsection (a) of this section.
(3) A DSHS screening certificate described in this section is valid for five years. Renewing a certificate is explained in paragraph (4) of this subsection.
(4) To renew a screening certificate, an individual must attend a recertification course either offered directly by DSHS, or approved by DSHS and provided by an external instructor before the certificate expires. If an individual does not complete the recertification within five years, the individual must take the complete certification training course again.
(5) DSHS may change, suspend, or cancel a certificate. DSHS will provide notice to the affected screener of any action being taken if DSHS receives information that the screener has not followed the rules in this subchapter.
(6) If a screener receives a notice of action, the screener has 20 business days to request a hearing. DSHS assumes the notice is received five days after being postmarked. Unless the notice specifies another method, the hearing request must be in writing and mailed or hand-delivered to the program at Vision, Hearing, and Spinal Screening Program, Department of State Health Services, Mail Code 1818, P.O. Box 149347, Austin, TX 78714-9347. If the request is not received or postmarked within 25 business days from the notice date, the screener waives the right to a hearing and DSHS may proceed with the action.
(7) Appeals and administrative hearings follow DSHS fair hearing rules in §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).
(c) DSHS may train individuals to become DSHS-authorized external instructors. These external instructors may train and certify individuals who screen children in facilities. Instructors may not charge fees for these activities.
(1) An individual who wants to become an external instructor must apply and meet the following requirements:
(A) the applicant has a valid DSHS screening certificate and has experience performing screenings; and
(B) the applicant has experience training groups of adults.
(C) An individual who meets the qualifications in subsection (c)(1)(A) - (B) of this section may submit an external instructor application, available on the DSHS website. DSHS will grant or deny the request based on the qualifications described in subsection (c)(1)(A) - (B) of this section and the external instructor manual located on the DSHS website.
(2) DSHS prioritizes applications from facilities and areas with a high training need.
External instructors must hold at least one training session for each type of screening every year to stay certified. The training may be either basic training or recertification training. For example, an external instructor may meet the training requirement for the year by conducting a basic training for hearing screening and a recertification training for vision screening.
(3) The DSHS external instructor certificate lasts for five years. To renew an external instructor certificate, an individual must complete an instructor recertification course before the current certificate expires. If an individual does not recertify within the required time period, the individual must take the complete training course again. DSHS may not renew an external instructor's certificate if DSHS confirms the individual did not fulfill all requirements during the previous certification period.
(4) DSHS-authorized external instructors must use the approved training materials from DSHS and follow all requirements and expectations listed in the instructor training manual.
(5) Instructors who have a valid certification may also teach courses for screener recertification. Instructors must make sure the individuals signing up for these recertification courses are eligible. Instructors must follow all the rules for these recertification courses.
(6) External instructors must turn in all documentation listed in the external instructor training manual in the specified manner and timeframe. Instructors must keep a copy of all records for five years.
(7) External instructors may certify or recertify screeners but cannot certify instructors.
(8) External instructors must follow all DSHS guidelines in the external instructor training manual, including rules about class size and duration, course and instructor evaluations, and testing. The manual also explains what happens if external instructors do not follow these rules.
(9) External instructors must follow all instructions given in the vision or hearing screening manuals, or both, which can be found on the DSHS website.
(10) External instructors may be audited or observed by DSHS at any time for quality checks without notice or permission.
(11) If DSHS gets any information that an external instructor has not followed the rules described in this subchapter, DSHS may modify, suspend, or cancel the certification. DSHS will notify the instructor about any proposed actions.
(12) DSHS will inform facilities or school districts when an external instructor fails to follow all the rules, instructions, policies, and manuals in this subchapter. If the instructor continues to not follow the rules, the instructor's certificate may be canceled.
(13) The instructor has 20 business days after receiving the notice to request a hearing about the proposed action. The notice is considered received five business days after being postmarked. Unless the notice states otherwise, the request for a hearing must be written and mailed or hand-delivered to the address described in subsection (b)(6) of this section. If the request for a hearing is not received or postmarked within 25 business days from the date the notice was sent, the instructor waives the right to a hearing and DSHS may take action.
(14) Screeners trained by a former external instructor with a revoked certificate will not be certified by DSHS.
(15) Appeals and administrative hearings follow DSHS fair hearing rules described in §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).
§37.28.
(a) Unless specified otherwise, all audiometers and other hearing equipment used for hearing screens in facilities must follow the rules described in this subchapter. The facility and the screener must make sure these requirements are met.
(b) The equipment mentioned in subsection (a) of this section must meet the relevant current ANSI standards, or the manufacturer's specifications if there are no ANSI standards, and must follow all other applicable federal and state standards and regulations for such equipment.
(c) Screeners in facilities must be certified by the Department of State Health Services (DSHS) in how to properly use the equipment, as explained in §37.27 of this subchapter (relating to Standards and Requirements for Screening Certification and Instructor Training).
(d) Qualified technicians must perform annual electronic calibrations and complete exhaustive electronic calibrations on audiometers used for screenings in facilities. The technician must provide proof of calibration to the audiometer's owner. Proof of calibration may be shown with a decal or sticker attached to the audiometer or the screener may keep a paper copy of the latest calibration documentation with the audiometer.
(e) The owner of the audiometer or the person in charge at the facility must complete biological calibration checks once a month on all audiometers used in facilities for screenings.
(f) The screener should conduct a brief pre-screen operational check to make sure the headset is operating properly.
(g) Every facility or screener for a facility that uses audiometric screening equipment must keep records of the equipment's calibration and monthly biological calibration checks. These records must be kept for three years and made available to DSHS if requested for inspection.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 20, 2026.
TRD-202600180
Cynthia Hernandez
General Counsel
Department of State Health Services
Effective date: February 9, 2026
Proposal publication date: October 10, 2025
For further information, please call: (512) 776-2008