TITLE 25. HEALTH SERVICES

PART 1. DEPARTMENT OF STATE HEALTH SERVICES

CHAPTER 37. MATERNAL AND INFANT HEALTH SERVICES

SUBCHAPTER C. VISION AND HEARING SCREENING

The executive commissioner of the Texas Health and Human Services Commission (HHSC), on behalf of the Department of State Health Services (DSHS), proposes 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.

BACKGROUND AND PURPOSE

The proposal is necessary to comply with House Bill (HB) 1297, 88th Legislature, Regular Session, 2023, which allows electronic eye charts for childhood vision screenings in public and private schools, licensed childcare centers, and licensed childcare homes. The proposed amendments define electronic eye charts and permit their use for visual acuity screenings. The proposal also includes edits to improve clarity and readability, defines terms, adds referral requirements from training materials, removes unnecessary procedural steps and details, removes a photoscreener training requirement, ends audiometer registration, requires facilities and certificate holders to comply with the program's policy and procedures manuals, adds an optional hearing screen for children with disabilities or for those who do not pass their initial hearing screening, and clarifies who may become a certified screener or external instructor.

SECTION-BY-SECTION SUMMARY

The proposed amendment to §37.21 edits language for clarity and readability.

The proposed amendment to §37.22 adds definitions for: electronic eye chart to comply with HB 1297; instrument-based vision screeners, which is a general term for certain vision screening equipment; optotypes, which are the standardized figures or letters used for visual acuity screening; otoacoustic emissions (OAE) testing, which is a hearing screen that tests vibrations of the inner ear in response to sounds emitted by a probe; screener, which refers to a person who conducts screenings; and vision disorder, which is a broad term for many eye problems. The proposal updates the definitions of "biological calibration checks," "calibration," "exhaustive calibration," "licensed professional," and "visual acuity," and replaces the definitions of "certification" with "certificate" and "photoscreening" with "photoscreener." The proposal edits definitions for clarity and readability. The proposal also updates a reference to the Texas Health and Safety Code.

The proposed amendment to §37.23 adds electronic eye charts for visual acuity screenings to comply with HB 1297. The proposal adds the requirement for children aged four years and younger to be referred for a professional eye examination if either eye cannot identify the majority of optotypes on the 20/40 visual acuity line. The proposal adds an example of a two-line difference on a visual acuity chart. The proposal specifies that screener training and certification is required only for screeners who screen children in facilities and not in other locations. The proposal adds a referral form to the vision screening referral process that is in the training manual.

The proposed amendment to §37.24 edits language for clarity and readability. The proposal removes step-by-step instructions for conducting an extended recheck and makes the extended recheck optional, allowing screeners greater discretion when referring a child for further evaluation. The proposal specifies screener training and certification is required only for screeners who screen children in facilities and not in other locations. The proposal adds a referral form to the hearing screening referral process. The proposal allows screeners to determine when a follow-up screen should be conducted. The proposal adds otoacoustic emissions (OAE) testing as an optional screen for children with disabilities.

The proposed amendment to §37.25 replaces wording and updates the rule title to include of State Health Services (DSHS), "Facility Requirements; Department of State Health Services (DSHS) Activities." The proposal changes the screening timeline from any time in the school year to within 120 calendar days of enrollment to allow for early intervention. The proposal adds that an affidavit for screening exemption must be submitted on or before the day the screening is scheduled. The proposal adds that facilities must verify a screener has a valid DSHS screening certificate prior to screening. The proposal adds that DSHS will notify facilities and school districts when external instructors do not comply with the rules and the external instructor manual. The proposal also explains consequences for repeated non-compliance, which may include cancellation of the instructor's certificate.

The proposed amendment to §37.26 adds electronic eye charts to recordkeeping and reporting requirements to comply with HB 1297 and updates the website address for the DSHS Vision and Hearing Screening Program. The proposal specifies screeners for facilities must comply with recordkeeping and reporting requirements. The proposal removes the specific mention of telebinocular screening. The proposal removes the requirement for screeners to submit documentation of certifications and refresher courses for specific vision screening equipment. The proposal updates the program mail code. The proposal changes the deadline by which screeners must submit screening results to a facility from "same day" to "no later than three business days after the day of screening." The proposal adds OAE testing to the reporting and recordkeeping requirements.

The proposed amendment to §37.27 replaces the term "instructor" with "external instructor," replaces additional wording, and edits language for clarity and readability. The proposal specifies screeners in facilities who are not licensed professionals must be certified by DSHS. Further, the definition of licensed professional in §37.22(17) does not include nurses, and therefore nurses must be certified by DSHS. The proposal adds that screeners must follow manufacturer instructions for all instrument-based screening devices. The proposal adds an example of the certificate deadline. The proposal clarifies that screener certification is not intended for medical office staff, nursing students, and individuals who are not screening children in facilities. The proposal adds that DSHS may train a limited number of certified vision or hearing screeners, or both, to become DSHS-certified external instructors who may train and certify screeners, but not other instructors. The proposal adds that DSHS accepts applications to become an external instructor on a limited basis and describes how instructor applications are prioritized. The proposal states external instructors must follow the rules and the external instructors' manual. The proposal changes the external instructor certificate period from five years to two years and makes external instructors subject to audits and observations. The proposal adds that instructors must maintain a copy of all training records for five years. External instructors must conduct each type of screener training at least once a year to maintain their certificate. This includes basic training and recertification training for vision or hearing, or both. External instructors who do not train screeners for over 18 months must reapply for certification.

The proposed amendment to §37.28 removes the requirement for registration of all pure-tone audiometers and the requirement for DSHS to approve all audiometer technicians. The proposal adds American National Standards Institute as the organization to follow for hearing equipment standards. The proposal clarifies all audiometer standards and requirements apply to audiometers used for hearing screening in facilities. The proposal requires screeners or facilities to store proof of calibration with the audiometer. The proposal requires audiometer biological calibrations both monthly and on each screening day, and the calibration records must be kept for three years.

FISCAL NOTE

Christy Havel Burton, Chief Financial Officer, has determined that for each year of the first five years the rules will be in effect, enforcing or administering the rules does not have foreseeable implications relating to costs or revenues of state or local governments.

GOVERNMENT GROWTH IMPACT STATEMENT

DSHS determined that during the first five years that the rules will be in effect:

(1) The proposed rules will not create or eliminate a government program;

(2) Implementation of the proposed rules will not affect the number of DSHS employee positions;

(3) Implementation of the proposed rules will result in no assumed change in future legislative appropriations;

(4) The proposed rules will not affect fees paid to DSHS;

(5) The proposed rules will not create a new regulation;

(6) The proposed rules will repeal existing regulations;

(7) The proposed rules will not change the number of individuals subject to the rules; and

(8) The proposed rules will not affect the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Christy Havel Burton has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities because there is no requirement to alter current business practices. No rural communities contract with DSHS in any program or service affected by the proposed rules.

LOCAL EMPLOYMENT IMPACT

The proposed rules will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to these rules because the rules do not impose a cost on regulated persons and the rules are necessary to implement legislation that does not specifically state that §2001.0045 applies to the rules.

PUBLIC BENEFIT AND COSTS

Dr. Manda Hall, Deputy Commissioner, Community Health Improvement Division, determined that for each year of the first five years the rules are in effect, the public benefit will be to give vision screeners more flexibility by allowing them to use electronic eye charts for screenings and to make the vision and hearing screening rules easier to understand and therefore follow.

Christy Havel Burton has determined that for the first five years the rules are in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rules because the use of electronic eye charts for visual acuity screenings is optional.

TAKINGS IMPACT ASSESSMENT

DSHS has determined the proposal does not restrict or limit an owner's right to the owner's property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Written comments on the proposal, including information related to the cost, benefit, or effect of the proposed rules, as well as any applicable data, research, or analysis, may be submitted to Rules Coordination Office, P.O. Box 13247, Mail Code 4102, Austin, Texas 78711-3247, or street address 4601 West Guadalupe Street, Austin, Texas 78751; or emailed to HHSRulesCoordinationOffice@hhs.texas.gov.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 25R010" in the subject line.

STATUTORY AUTHORITY

The amendments are authorized by 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 services by the health and human services system. The amendments are required to comply with Texas Health and Safety Code Chapter 36.

The amendments affect Texas Government Code §524.0151 and Texas Health and Safety Code §§36.002 - 36.006 and §36.011, and Chapter 1001.

§37.21. Purpose.

This [The purpose of this] subchapter implements [is to implement] Texas Health and Safety Code[,] Chapter 36, concerning the early identification of individuals from birth through 20 years new old [of age] who have special senses and communication disorders and [who] need remedial vision, hearing, speech, or language services.

§37.22. Definitions.

The following words and terms, when used in this subchapter, [ shall ] have the following meanings, unless the context clearly indicates otherwise.

(1) American Academy of Pediatrics (AAP)--A [The AAP is a nationally recognized] professional organization that makes health recommendations for [which issues recommended standards pertaining to the health and well-being of] children.

(2) American Association for Pediatric Ophthalmology and Strabismus (AAPOS)-- A professional organization that, along [AAPOS is a nationally-recognized professional body which, in conjunction] with the AAP, sets [issues] recommended vision screening standards. [The goals of] AAPOS works to improve [are to advance the quality of] children's eye care, supports [support] the training of pediatric eye doctors, supports pediatric eye [ophthalmologists, support] research [activities in pediatric ophthalmology], and helps [advance the care of] adults with alignment issues [strabismus].

(3) American National Standards Institute, Inc. (ANSI)--A [The] national organization that provides [coordinator of standards development and the United States clearinghouse for] information about [on national and international] standards used in the United States and around the world.

(4) Audiometer--A [An electrical] device used to test [for testing] hearing[,] and measure how well a person can hear different levels and pitches [for measuring bone and air conduction] of sound.

(5) Audiometric calibration equipment--Electronic devices used to adjust [Electro-acoustical equipment used to calibrate] audiometers and audiometric testing devices, which [. The term] includes frequency counters, voltmeters, and distortion measuring equipment [used to calibrate audiometers and audiometric testing devices].

(6) Audiometric testing device--A machine that uses a variety of [An electro-acoustical generator that provides acoustic energy of a] calibrated sounds to test hearing and help identify the presence, type, and severity of hearing loss [output].

(7) Biological calibration check--A method to check an audiometer's accuracy by testing the device on an individual with known hearing levels [The process of testing a person having a known, stable audiometric curve that does not exceed 25 decibels (dB) hearing level at any frequency between 250 and 6000 Hertz (Hz), and comparing the test results with the subject's known baseline audiogram].

(8) Calibration--The process of comparing an instrument or device to [with] a standard and making adjustmentsto an acceptable level of [determine its] accuracy [and to make the necessary repairs or adjustments to assure that the operating characteristics are within the allowable limits established by a national standard, all in accordance with applicable legal requirements].

(10) dB--The decibel is a unit for measuring [expressing] the loudness [relative intensity] of sounds. Decibels range [on a scale] from zero, which is the quietest sound an average person can hear, up [for the average least perceptible sound] to around [approximately] 130, which is [for] the average [pain] level of sound that causes pain.

(12) [(11)] Exhaustive calibration--An audiometer [A] calibration that tests all settings for both earphones.

(13) [(12)] Extended recheck--A hearing test [screen] used after a [the] child has failed two sweep-check screens. [The screener may perform an extended recheck or initiate a referral for a professional examination, as defined in this section, after the two failed sweep-check screens.]

(14) [(13)] Facility--Includes public and [or] private preschools and schools, [as] defined as follows:

(A) schools, as [the term is] defined in [at] Texas Health and Safety Code §36.003[, §36.003(7)];

(B) preschools, as [the term is] defined in [at] Texas Health and Safety Code§36.003[, §36.003(3)];

(C) child care centers licensed by the Health and Human Services Commission (HHSC) [Department of Family and Protective Services (DFPS)]; and

(D) child care homes licensed by HHSC [DFPS].

(15) [(14)] Hz--Hertz is a unit of frequency equal to one cycle per second.

(17) [(15)] Licensed professional--An individual who is legally allowed to conduct [whose legally-defined scope of practice under the license includes knowledge and experience in conducting] professional examinations, make diagnoses, and perform screenings for vision or [and/or] hearing abnormalities, or both, in children. This must be done according to[, all consistent with] this subchapter and Texas Health and Safety Code[,] Chapter 36. The term "licensed professional" in this subchapter does not include nurses. [The terms "professional examination" and "screening" are as defined in this section.]

(20) [(16)] Pass/Fail--Allowable documentation of results if [of vision screening when] photoscreening is used for vision screening, as outlined in [accordance with] this subchapter. [The documentation of the screening results is in lieu of visual acuity results using "20/20" format.]

(22) [(18)] Professional examination [(also referred to as examination)]--A diagnostic evaluation performed by a [an appropriately] licensed professional who has the [or by a department-certified individual whose] expertise to address [addresses] the diagnostic needs of an [the] individual with [identified as having a] possible vision or hearing issues [special senses or communication disorder]. This [A professional] examination meets [is one that is done according to] the requirements of this subchapter and [of the] Texas Health and Safety Code[,] Chapter 36.

(23) [(19)] Program--DSHS [The department's] Vision and Hearing Screening Program.

(24) [(20)] Pure-tone audiometer--A device that [pure-tone audiometer] electronically generates pure tones [pure-tones which are] used as signals to test an individual's [a person's] hearing.

(25) [(21)] Reporting year--A 12-month period beginning June 1 of each year and ending May 31 of the next [following] year.

(27) [(22)] Screening--A quick test or set [battery] of tests to see if someone might [for rapidly determining the] need [for] a professional examination.

(28) [(23)] Screening equipment--An instrument or device used to measure [perform a measurement or measurements for the assessment of] sensory abilities.

(29) [(24)] Sweep-check--A quick hearing [screening] test using a pure-tone audiometer to check if an individual [determine whether a person] can hear tones at [the following frequencies:] 1000 Hz, 2000 Hz, and 4000 Hz at [less than or equal to] 25 dB.

(30) [(25)] Telebinocular instrument--A device used to check [stereoscopic instrument] for [screening] various eye defects and measure [measuring] visual acuity.

(31) [(26)] Testing equipment--An instrument or device used as described in [under] this subchapter to check for [perform a measurement or measurements to substantiate or verify the presence or absence of] sensory problems [impairment(s)].

(32) [(27)] Tests--Procedures used as described in [under] this subchapter to measure special senses and communication functions.

(34) [(28)] 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, [relative ability of the visual organ to resolve detail that is] measured as a standard ratio like [and recorded using an internationally recognized, two-figured indicator, such as] 20/20.

§37.23. Vision Screening.

(a) Visual acuity screening [Screening] is required to find specific vision disorders[,] for individuals attending [who attend] a facility[, to detect vision disorders]. The vision screening rules follow national standards from AAPOS. Vision screening as described [conducted under this subchapter by a person who is not a licensed professional, as the term is defined] in this subchapter must meet the following requirements[, must be conducted following the national standards set by AAPOS currently found at http://www.aapos.org/terms/conditions/131, as revised, as they apply to age, verbal ability, ability to cooperate with screening, allowable methods of screening in different situations, and referral criteria, with the following exceptions].

(2) [(1)] Refer children aged four years and younger [For children less than five years of age, refer] for a professional examination if either eye cannot correctly identify the majority of optotypes on the 20/40 acuity line or if [when] 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.

(3) [(2)] Refer [For] children aged five years [of age] and older[, refer] for a professional examination if either eye cannot correctly identify the majority of optotypes on the [when screening results indicate visual acuity of less than] 20/30 line. The DSHS requirement differs from the AAPOS standard of 20/32 [in either eye (rather than 20/32 as listed in the AAPOS standards)].

(5) [(3)] Use [In addition to AAPOS' recommendation regarding] photoscreening, when applicable, for children aged 42 months to five years [of age], as recommended by AAPOS, and for individuals [photoscreening may be used for any individual (referenced in §37.21 of this title (relating to Purpose)] with disabilities who do [does] not respond well to other [allowable] screening methods. Refer a child for [A referral to] a professional examination if the child fails [is recommended if the individual fails] the photoscreening.

(b) A screener [person] who is not a ["]licensed professional and[," as that term is defined in this subchapter, who] conducts vision screening in facilities must be trained and certified as described in §37.27 of this subchapter [title](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 screening. The referral is for further evaluation by an appropriate licensed professional. Facilities must not refer a child [When a screener makes a referral based on the screening results under subsection (a) of this section, that referral shall be to a licensed professional for a professional examination, and not] to a specific person [individual].

(d) A individual is exempt from [The requirements of] this section if the individual gives the facility [do not apply when the individual is already actively under medical care by an appropriate licensed professional for one or more of the vision problems for which screening is done under this section. In order to claim this exception, the individual under the scenarios described at Texas Family Code, §32.003 or, if the individual is a minor, the individual's parent, managing conservator or legal guardian, must submit] documentation from an appropriate [the] licensed professional stating [to the facility. The documentation must be signed and dated by the licensed professional, and must affirmatively state that] the individual is under active or[,] ongoing medical care [from the licensed professional] for a [specific] vision problem [problems as referenced in this subsection].

§37.24. Hearing Screening.

(a) Hearing screening to detect hearing disorders [Screening] is required[,] for individuals attending [who attend] a facility[, to detect hearing disorders]. Hearing screening as described in [under] this subchapter must meet the following [be conducted using screening methods and referral criteria, and in compliance with other] requirements[, as follows].

[(b)] [A person who is not a "licensed professional," as that term is defined in this subchapter, who conducts hearing screening must be trained and certified as described in §37.27 of this title (relating to Standards and Requirements for Screening Certification and Instructor Training).]

(1) [(c)] Use a [A] pure-tone audiometer [shall be used] to perform [conduct] a sweep-check screen.

(2) [(d)] Record the screening [Screening] results [shall be recorded] for each ear at less than or equal to 25 dB for 1000 Hz, 2000 Hz, and 4000 Hz.

(3) [(e)] If the results show that the child did not respond to any of the three frequencies in either ear, perform a second sweep-check screen. If the child has a cold, congestion, fluid buildup in the ears, or any other condition impacting hearing, delay the second sweep-check screen. Perform the rescreening no later [A rescreen with another sweep-check is recommended if test results indicate failure to respond to any of the three frequencies in either ear, and it should be conducted no sooner than three weeks but not more] than28 calendar days [four weeks] after the initial screening.

(4) [(f)] If the child does not respond to any of the frequencies [An extended recheck may be conducted or a referral to a professional examination shall be made for all children whose test results indicate failure to respond to any of the three frequencies] in either ear on the second sweep-check, either perform an optional extended recheck or refer the child for a professional examination.

(5) [(g)] Refer a child for professional examination if the child does not respond [If the extended recheck results in a failure to respond] to any frequency in either ear above 25 dB during an extended recheck [at greater than 25dB, the screener must recommend that a professional examination be immediately conducted].

§37.25. Facility Requirements; Department of State Health Services (DSHS) Activities.

(a) The chief administrator must [of each facility shall] ensure [that] each individual admitted to the facility follows these [complies with the] screening requirements [of this subchapter (including ensuring that any screening done is performed by a properly certified screener), according to the following schedule].

(1) Children ages four and [years of age or] older as of September 1 of the school year[,] who are enrolled in any facility for the first time[,] must have [be screened for possible] vision and hearing tests [problems] within 120 calendar days of enrolling [enrollment]. If a child enrolls [is enrolled] within 60 calendar days of the end of the school year [date a facility closes for the Summer], the child's vision and hearing must be tested within 120 calendar days of the start [beginning] of the next [following] school year.

(2) Children [enrolled] in pre-kindergarten and kindergarten must be screened each year within 120 calendar days of enrollment.

(3) Children [enrolled] in the first, third, fifth, and seventh grades must be screened for [receive] vision and hearing problems within 120 calendar days of enrolling in each of those grades to allow for early intervention if a problem is found [screening in each of those grade years (can be done at any time during each of those years)].

(4) Children in third, fifth, and seventh grades are [Except for children enrolled in pre-kindergarten, kindergarten or first grade, a facility shall] exempt [any child] from screening as required in [by paragraphs (1) - (3) of] this subsection if the child's parent, managing conservator, or legal guardian, or the individual in [under] the scenarios described in [at] Texas Family Code[,] §32.003, submits a record to the facility showing [that] a professional examination was [properly] conducted during the grade year in question or [during] the previous year. The record must be submitted to the facility during the grade year when [in which] the screening would otherwise be required.

(5) Children turning [enrolled in a facility who turn] four years old [of age] after September 1 of the school [that] year do not need to be screened [are exempt from screening] until the next school year [following September].

(6) Children may be screened [Upon written request pre-approved by the department, the screening of vision and hearing performed at a facility may occur] on an alternate [even-year] schedule (i.e., pre-kindergarten, kindergarten, [and] first, second, fourth, and sixth grades) if DSHS approves a written request. DSHS may set [instead of pre-kindergarten, kindergarten, and first, third, fifth, and seventh grades). Any department approval will include] conditions so [that] children receive [do not miss] necessary screenings [screening] during the transition.

(b) A child's parent, managing conservator, or legal guardian, or the individual in [under] the scenarios described in [at] Texas Family Code[,] §32.003, may execute an affidavit stating either [that] a screener [person,] other than the screener selected [individual secured] by the facility will perform [to conduct screenings at the facility, shall conduct] the screening [(] or [that] a licensed professional will perform [shall conduct] an examination[)] as soon as possible [is feasible]. The facility may admit the child temporarily [on a provisional basis] for up to 60 calendar days[,] or may deny admission until the screening record is [record(s) are] provided [to the facility].

(c) A [facility shall not require a] child is exempt from screening [to be screened] if the child's parent, managing conservator, or legal guardian, or the individual in [under] the scenarios described in [at] Texas Family Code[,] §32.003, submits an affidavit to the facility[, on or before the date vision or hearing screening is scheduled, an affidavit in lieu of the screening record(s)] stating [that] the vision or hearing screening, or both screenings, conflict [conflicts] with the tenets and practices of a church or religious denomination of which the child or individual is a [affiant is an adherent or] member. The affidavit must be submitted on or before the day the screening is scheduled.

(e) [(d)] Volunteers must have a [Only individuals who have completed] high school diploma or equivalent to help with [may serve as volunteer assistants during] vision and [and/or] hearing screenings. The screener is responsible for deciding [It is the responsibility of the certified screener to determine] how a [any] volunteer [assistant(s) ] will assist with [be used during] the screening process, consistent with all state and federal confidentiality requirements.

§37.26. Recordkeeping and Reporting.

(a) Screeners at facilities [Individuals conducting screenings under this subchapter] must follow the rules for keeping records [comply with the following recordkeeping] and reporting information [requirements].

(1) A screener must [Individuals conducting screenings at the facility (and those other than licensed professionals conducting screenings outside of the facility) shall] document in each child's screening record the specific screening performed [conducted], the date the screening was performed [conducted], observations made during the screening, and the final results [of the screening]. The screener must document [individual shall also ensure that the following are included in the documentation:] the child's name [of the child], age or birthdate [of the child], and if [whether] the child is wearing corrective lenses during the vision screening. The screener [documentation required under this subsection] must sign [also be signed] and date this information [dated by the person who conducted the screening].

(3) [(4)] Screeners [Individuals conducting screenings] at a facility must [(and those other than licensed professionals conducting screening outside of the facility) shall] 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 [at] the [time of that] screening.

(b) Facilities must follow the rules for keeping records [comply with the following recordkeeping] and reporting information [requirements].

(1) A [Each] facility must [shall] maintain vision and hearing screening records [under this section] onsite for at least two years.

(2) A facility must maintain [screening] records of screening [regarding any individual claiming the] exemptions found in [§37.23(d) of] this subchapter [title (relating to Vision Screening) and/or §37.24(j) of this title (relating to Hearing Screening)] for at least two years.

(3) A facility must [shall] maintain the records received [it receives] from screeners [under subsection (a)(2) of this section, related to the use of photoscreening for vision screening at the facility] for at least two years.

(4) A child's [An individual's] screening records may be transferred between [among] facilities without [the] consent of the child's parent, managing conservator, or legal guardian, or the individualin [under] the scenarios described in [at] Texas Family Code[,] §32.003 , according [or, if the individual is a minor, the minor's parent, managing conservator, or legal guardian, pursuant] to Texas Health and Safety Code[,] §36.006(c).

(5) Facilities [The recordkeeping required in this section] must provide the required records [be made available] to DSHS [the department] in a timely manner if requested [upon request]. DSHS or its representatives [The department] may[, directly or through its authorized representative,] enter a facility and inspect vision and hearing screening records [maintained relating to vision and hearing screening].

(6) Each [On or before June 30 of each year, each] facility must [shall] submit a yearly [to the department a complete and accurate annual] report on the vision and hearing screening status of the [its] aggregate population screened during the reporting year. The report must be submitted on or before June 30 of each year [Facilities shall report] in the manner specified by DSHS at https://www.dshs.texas.gov/vision-hearing-screening [the department (currently found at http://chrstx.dshs.state.tx.us). Facilities are required to report on the following categories].

(A) Hearing [For 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 [transferred out of] the facility before [prior to] the facility received [receiving] the professional examination results; professional examination results showing [indicating] none of the screened disorderswere present [which are screened for under this section]; professional examination results showing a disorder was [indicating a disorder(s) which is] screened for [under this section]; and referrals [referral] for a professional examination where [with] no [indication that a] professional examination was [ever] done.

(B) Vision [For vision] screening--The total number of children screened, including[;] the [total] number screened with glasses or contact lenses [correction (e.g. glasses or contacts)]; the [total] number screened with photoscreening; the number screened with an electronic eye chart; the number who failed; the number referred for professional examination; the number who left [transferred out of] the facility before [prior to] the facility received [receiving] the professional examination results; the number whose professional examination results indicated no issues [indicating none of the disorders present which are screened for under this section]; the number whose professional examination results indicated an issue [indicating a disorder(s) which is screened for under this section]; and the number referred [referral] for a professional examination where [with] no [indication that a professional] examination was [ever] done. The ["]total number screened["] includes the number screened with telebinocular screening.

(c) Additional [There are additional] recordkeeping requirements [in §37.28(f) and (g) of this title (relating to Hearing Screening Equipment Standards and Requirements)] for screeners [individuals or entities] who own or [and/or] use audiometers and audiometric screening equipment are in §37.28(f) of this subchapter (relating to Hearing Screening Equipment Standards and Requirements).

(d) Unless otherwise specified on the DSHS website, send documents described in [For all submissions to the department under] this subchapter to [, use the following contact information (unless otherwise specified):] Vision, Hearing, and Spinal Screening Program, Department of State Health Services, Mail Code 1818 [1978], P.O. Box 149347, Austin, Texas 78714-9347.

§37.27. Standards and Requirements for Screening Certification and Instructor Training.

(a) A screener working in a facility [Individuals who conduct vision and/or hearing screening] must be certified by the Department of State Health Services (DSHS) [under this section] unless the screener [screening] is [conducted by] a licensed professional. Training for screeners is provided either [There are two options for obtaining this certification: a certificate issued] directly by DSHS or by instructors [the department; or a certificate issued by an instructor who has been trained and] authorized by DSHS [the department] to issue certificates. There is no fee for [cost to] taking the course in either case [scenario].

(1) DSHS provides training [The department offers certification courses,] and issues certificates when the course is completed. To join, participants [to those who successfully complete them. To be eligible to take the department's certification course, an individual] must have [be] a high school diploma or equivalent [graduate] and sign a form [written statement to that effect] at the start [beginning] of the course. Individuals who finish the training and pass [successfully complete the course, including passing] the [associated] tests[,] will receive [be issued] a certificate from DSHS to conduct screenings [by the department].

(3) [(2)] DSHS may train certain people outside the screening program, called external instructors, to conduct [The department trains instructors who themselves give] certification courses. Screeners who finish the course and pass the tests[, as described in this section. The eligibility requirement to attend such a course is the same as is described at paragraph (1) of this subsection. Individuals who successfully complete the course, including passing the associated tests,] will receive [be issued] a certificate from DSHS [signed by the authorized instructor. It will have the same validity, and is subject to the same restrictions, as a certificate issued under paragraph (1) of this subsection].

(b) Holders of [Screening] certificates issued as described in [under] this section must follow these [are subject to the following] requirements.

(1) Certificate holders may [Individuals who receive a certificate are authorized to] conduct the type of [vision and/or hearing] screening [(as applicable to the course taken, and as] listed on the certificate[), [in accordance with this subchapter]. Certificate holders must follow all the rules in [Certified screeners are required to comply with] this subchapter, and failure to do so may lead to modifications, [is grounds for the modification,] suspension, or cancellation [and/or revocation] of the certificate [certification as provided in this section].

(2) If a screener uses [Individuals using] a photoscreener or other instrument-based device for vision screening, the screener must follow the manufacturer's instructions. The screener [have successfully completed instrument-specific training (including passing all associated tests) in accordance with manufacturer guidelines and must have a full understanding of the pass/fail referral criteria in accordance with AAPOS standards. Individuals conducting photoscreening must] also needs [have] a current DSHS screening certificate as described in [under] subsection (a)[(1) or (2)] of this section. [Documentation of the photoscreening training must be submitted to the instructor upon attendance at a certification class and include the date and location the training was taken, and the name, affiliation and contact information of the instructor. The individual must successfully complete instrument-specific refresher training (including passing any associated tests) every five years. Such refresher training must be completed during the fifth year of certification from the date the preceding certificate was issued.]

(3) If a screener uses [Individuals using] a telebinocular instrument for vision screening, the screener mustfollow the manufacturer's instructions. The screener [be familiar with the instrument in accordance with manufacturer guidelines and must have a full understanding of the pass/fail referral criteria. Individuals conducting telebinocular screening must] also needs to have a currentDSHS screening certificate as described in [under] subsection (a)[(1) or (2)] of this section.

(4) A DSHS screening certificate described in [Screening certification under] this section is valid [allows the individual to screen children for vision and/or hearing problems (as applicable to the course taken, and as listed on the certificate) under this subchapter] for [a period of] five years. Renewing a certificate is explained[, with renewals processed as described] in paragraph (5) of this subsection.

(5) 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. [Screening certification may be renewed by attending a department-approved refresher training course (either offered directly by the department or by an instructor authorized under this section).] The individual must finish this course by December 31 of the fifth year after the certificate was issued. For example, if the certificate is dated March 15, 2026, an individual has until December 31, 2031, to finish the recertification course, which then extends the certificate for another five years. If an individual does not complete the recertification within five years, [refresher training course must be completed during the fifth year of certification from the date the preceding certificate was issued. Once a refresher training course is successfully completed, the five-year cycle begins again. If certification is not renewed within the required time period,] the individual must take the complete [attend the basic] certification training course again [(i.e., a refresher course will not be sufficient)].

(6) DSHS may change, suspend, or cancel a certificate. DSHS will provide notice to the affected screener of any action being taken if DSHS receives [When the department receives] information that the [from any source that indicates a] screener has not followed [been following] the rules in [requirements of] this subchapter[, the department may modify, suspend, or revoke the certification. The department will send a notice to the affected individual as part of any such action being taken].

(7) If a screener receives a notice of action, the screener [The affected individual] has 20 business days [after receiving the notice, referenced in this paragraph,] to request a hearing. DSHS assumes the notice is received five days after being postmarked. [on the proposed action. It is a rebuttable presumption that a notice is received five days after the date of the notice.] Unless the notice [letter] specifies another [an alternative] method, the hearing [a] request must [for a hearing shall] be [made] in writing[,] and mailed or hand-delivered to the program at the address described [specified] in §37.26(d) of this subchapter [title](relating to Recordkeeping and Reporting). If [an individual who is offered] the [opportunity for a hearing does not] request is not received or postmarked within 25 business days from the notice date [a hearing within the prescribed time for making such a request], the screener waives [individual is deemed to have waived] the right to a hearing and DSHS [the action] may proceed with the action [be taken].

(8) Appeals and administrative hearings follow DSHS [will be conducted in accordance with the department's] fair hearing rules in[, at] §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).

(c) DSHS may train a limited number of certified vision or hearing screeners, or both, to become DSHS-authorized external instructors. These external instructors may train and certify individuals who screen children in facilities. [Individuals who successfully complete a department instructor training course, including all associated testing, are authorized to conduct screening trainings and issue screening certificates to individuals who successfully complete the screening training (including all associated testing), subject to the requirements of this section.] Instructors may not charge [any kind of] fees for these [their] activities [under this section].

(1) A screener who wants to become an external [Individuals wishing to take the] instructor [course] must apply and [first] meet the following requirements [qualifications]:

(A) the applicant has [have] a [current,] valid DSHS [department] screening certificate [certification,] and has [have] experience performing screenings [under that certificate];

(B) the applicant has [have] experience training [conducting trainings to] groups of adults; and

(C) the applicant is [be] an audiologist, speech pathologist, optometrist, ophthalmologist, or a registered nurse with a valid [and must have the applicable] Texas license[, current and ] in good standing [under Texas law].

(4) [(3)] DSHS-authorized external [Once authorized by the department to conduct trainings,] instructors must use the approved [do so using] training materials [obtained] from DSHS and follow all requirements and expectations listed in the instructor training manual [the department].

(5) [(4)] DSHS must approve all [All proposed screening] training sessions [must be approved by the department] at least 15 business [working] days before the sessions take place [prior to the training session]. The instructor must provide the necessary details to DSHS [all information sought by the department,] by the specified due date [deadlines given].

(6) [(5)] Instructors who have a valid certification [in good standing under this section] may also teach courses for screener recertification. Instructors must make sure the people signing up for these recertification courses are eligible. Instructors must follow all the rules for these recertification [screening refresher courses as described in subsection (b)(5) of this section. Such refresher courses are subject to the same requirements under this section as those pertaining to initial screening] courses.

(7) [(6)] External instructors must turn in all documentation listed in the external instructor training manual to DSHS within 10 business days after training screeners. The external instructor must send the [When a department-authorized instructor issues a certificate of vision and/or hearing screening, the instructor has 14 days to submit the attendance sheets, evaluations and the tear-off portion of the department's certification, and the photoscreening certificate, if applicable, to the department. These] original documents [should be submitted] to the [program at the] address listed in [found at] §37.26(d) of this subchapter unless instructed otherwise in the training manual or on the DSHS website. Instructors must keep [title. The instructor should maintain] a copy of all records for five years.

(13) [(8)] The instructor [affected individual] has 20 business days after receiving the notice[, referenced in paragraph (7) of this subsection,] to request a hearing about [on] the proposed action. The notice is considered received five business days after being postmarked. [It is a rebuttable presumption that a notice is received five days after the date of the notice.] Unless the notice states otherwise, the [letter specifies an alternative method, a] request for a hearing must be written [shall be made in writing,] and mailed or hand-delivered to the [program at the] address described [specified] in §37.26(d) of this subchapter [title]. If the [an individual who is offered the opportunity for a hearing does not] request for a hearing is not received or postmarked within 25 business day from the date the notice was sent, the instructor waives the right to a [within the prescribed time for making such a request, the individual is deemed to have waived the] hearing and DSHS may take [the] action [may be taken].

(14) [(9)] Appeals and administrative hearings follow DSHS [will be conducted in accordance with the department's] fair hearing rules described in [at] §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).

§37.28. Hearing Screening Equipment Standards and Requirements.

(a) Unless specified [Except as] otherwise, [specifically provided, the sections in this subchapter apply to all persons and entities (e.g., calibration companies, facilities) who receive, possess, acquire, transfer, own, or use audiometers, audiometric testing devices, and audiometric calibration equipment, and to] all audiometers and other hearing equipment used for hearing tests [audiometric screening and hearing threshold tests, all audiometric testing devices, and all audiometric calibration equipment used] in facilities must follow the rules described in this subchapter. The facility and the screener must make sure these requirements are met [the State of Texas].

(b) [(c)] The equipment mentioned [Equipment referenced] in subsection (a) of this section must [shall] meet the relevant [appropriate] current ANSI standards, or the manufacturer's specifications if there are no ANSI standards [apply], and must follow all other applicable federal and state standards and regulations [standard(s) and/or regulation(s)] for such equipment.

(c) [(d)] Screeners in facilities [Individuals] must be certified [trained] by [or undergo training approved by] the Department of State Health Services (DSHS) [department] in how to properly [the proper] use the [of this] equipment, as explained [detailed] in §37.27 of this subchapter [title] (relating to Standards and Requirements for Screening Certification and Instructor Training).

(d) [(f)] Qualified technicians must [Only calibration firms shall] perform regular [periodic] electronic calibrations and complete exhaustive electronic calibrations on audiometers used for screenings in facilities. The technician must [Calibration firms shall] provide proof of calibration [notification] to the audiometer's owner. Proof of calibration [of the audiometer being calibrated that the audiometer has been calibrated. The notification] may be shown with [in the form of] a decal or sticker attached [affixed] to the audiometer or the screener may keep a paper[, or in hard] copy of the latest calibration documentation with the audiometer [that must be maintained by the owner and be made readily available to the department or its representative upon request].

(f) [(g)] Every facility or screener for a facility that uses [Upon reasonable notice, each individual or entity using] audiometric screening equipment must keep [shall make available to the department, in a timely manner,] records of the equipment's calibration and [maintained pursuant to this subchapter. Calibration forms and records for all equipment referenced in subsection (a) of this section, including] monthly biological calibration checks. These records must be kept for three years and made available to DSHS if requested [data, shall be maintained] for inspection [by the department for three years].

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on September 26, 2025.

TRD-202503435

Cynthia Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: November 9, 2025

For further information, please call: (512) 776-7420