人工耳蜗救助项目申请表

人工耳蜗救助项目申请表 人工耳蜗救助项目 听障儿童姓名: 出生日期: 年 月 日 填表日期: 年 月 日 XXX省残疾人联合会印制 Security Bureau. of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control center for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automatically processing; through on operator grading management, can completely control each a operator in system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment statistics are as follows: security point distribution statistics-medical building, rehabilitation building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access control management system has been widely used in the new information security management systems, application access control systems to achieve the rehabilitation centers in 填报说明 一、此表为人工耳蜗救助项目申请专用表，用蓝色、黑色签字笔或钢笔完整填写表中各 项，如有缺项、漏项视为无效申请。 二、此表所列个项内容要求如实填写，所提供材料真实有效，否则将被取消申请资格。 三、此表由十六项内容组成，具体填写要求说明如下: (一)第一和第二两项由听障儿童法定监护人根据自身情况如实填写，其中“家庭 【1】年人均收入”指家庭上年度总收入除以家庭总人口。 (二)第三和第四项由专业人员协助听障儿童法定监护人如实填写。 (三)第五至第七项由听障儿童法定监护人提供家庭户口、身份证、家庭收入证明 【2】原件，由项目工作人员对上述内容与原件进行核对、确认并签字后粘贴 至指定位置，视为有效。 (四)第八至十四项由听障儿童法定监护人提供项目指定筛查机构或定点手术医 院出具的检查结果，项目工作人员应对其进行核对、确认后粘贴至指定位置， 核对签字有效。 说明:以填表日期计算，八至十项要求提供6个月以内的检查结果;十三、十四 项要求提供3个月内的检查结果，超过时间要求视为无效结果。 (五)第十六项由专业人员根据听障儿童实际情况填写并核对准确后签字有效。 四、报送要求 (一)此表需由本省填写“省残联推荐意见”，经项目负责人签章后方可上报，如有缺 项视为无效申请。 (二)报送此申请表的同时，报送相同内容电子文档，如缺任何一项将不予受理。 —————————————— 【1】家庭总收入包括四大部分: ?工资性收入:包括工资及补贴收入、其他劳动收入。 ?经营性净收入:指家庭成员从事生产经营活动所得的净收入。 ?财产性收入:包括利息收入、股息与红利收入、保险收入、其它投资收入、出租房屋收入、知识产权收入。?转移性收入:包括养老金或离退休金、社会救济收入、辞退金、赔偿收入、保险收入、失业保险金、赡养收入、捐赠收入、亲友搭伙费、提取住房公积金、记账补贴、其他转移收入。 【2】家庭经济收入证明:在职人员需出具所在单位核准盖章并签字的收入证明;离退休人员和失业人员由退休金和失业救济金发放单位出具;无工作单位的由户籍所在街道办事处(乡镇政府)出具收入证明。 medical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access c2 知情告知 在您决定是否申请人工耳蜗救助项目之前须仔细阅读以下内容，并签署知情同意书。 1、人工耳蜗救助项目是指中国残联组织实施的由政府或个人捐助人工耳蜗的项目。了解项目内容可以通过:(1)向当地残联康复部、聋儿康复中心咨询;(2)登陆网站:www.chinadeaf.org 查询; 2、申报流程 签署知情同意书 填写申请表 提交初筛查材料 本省审核 推荐上报国家项目办公室 项目办公室和资助方审核 定点医院复筛 确定受助资格并植入手术 重点强调:在初筛、审核和复筛这三个环节中的任何1个环节未通过均不能接受救助。 3、申请需要做好以下准备: (1)提供真实有效的申请材料(如:照片、身份证、经济收入证明、各项检查结果等)。 (2)家庭有能力承担与救助补贴之外的相关费用。 (3)要详细了解人工耳蜗植入术的风险及手术禁忌症。 (4)要了解人工耳蜗植入后调机的重要性以及调机的频次、费用。人工耳蜗植入术一个月后要在手术医院开机，开机后第一个月每周需要调机1次、第二个月每半个月调机1次、从第三个月起每月一次，以后根据具体情况不定期调机。调机的次数因个体差异而定。调机对于孩子的术后康复有非常重要的作用，原则上患者应在手术医院或有条件的康复机构进行术后调机。如果术后调机地点改变，每半年需回开机医院复诊一次。调机费按照当地的收费标准交纳。 (5)要在术前选择确定康复机构。为了保障每位接受人工耳蜗救助的孩子得到科学、的康复服务，国家项目办公室在全国范围内选择确定了定点康复机构，家长在申请时自主选择确定其中1家康复机构并签订。凡申请人工耳蜗项目的孩子必须在自行选定的康复机构接受术后一年的康复训练，并配合项目的长期术后跟踪评估。不得以任何理由拒绝接受康复训练。 (6)家庭要有专人陪伴孩子配合康复机构术后康复训练。人工耳蜗植入后孩子能够听见，但要听懂、会说需要长期的康复，家长在康复中的作用非常重要。 (7)家长要对术后康复效果有适当的期望值。术后康复效果与多种因素有关，如患者听力损失程度、术前及术后康复训练情况、家长配合程度、孩子智力水平和个体差异等，因此，如短期康复效果未能达到预期目标，应有心里准备并坚持长期的康复训练。 ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automaticle aland network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav 3 知情同意书 我已经阅读了上述有关项目的介绍，知道人工耳蜗植入可能产生的风险和申请的准备及要求。我自愿申请并做以下承诺: ?我承诺自愿承担人工耳蜗手术风险; ?我能够积极配合手术植入后调机工作，并做好相关费用的准备 ?我们会陪伴孩子做好术后长期的康复训练; ?我对人工耳蜗术后康复效果已有适当的期望值，对术后康复效果如未能达到预期目标有心理准备。 ?我已自愿选择确定在(______________ ______)接受至少一年的康复训练，并配合项目的长期术后跟踪评估。如擅自离开不接受定点康复机构的康复训练，项目提供的康复训练费用将被终止。 ?我承诺无偿提供孩子评估音像资料用于项目宣传和学术交流。 ?我自愿申请人工耳蜗捐赠项目，遵守项目的有关要求，服从项目的审核、耳蜗产品、手术医院等内容的安排。 听障儿童姓名(申请者):________________ 法定监护人签字(申明人):________________ 签字日期: 年 月 日 s,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monito4 人工耳蜗救助申请表 一、听障儿童一般情况: 听障儿童姓名 性 别 出生年月日 年 月 日 民 族 身份证号码 省(市) 市(区/县) 街道(乡镇) 居委会 街户籍所在地 (胡 同 / 小 区 / 村 街) 号(楼) 单元 室 省(市) 市(区/县) 街道(乡镇) 居委会 现居住地址 街(胡 同 / 小 区 / 街) 号(楼) 单元 室 通讯地址 户籍所在地 ? 现居住地址 ? 居住地住宅电 邮编 话 二、家庭基本情况: 是否单亲:是? 否? 父亲姓名 职 业 文化程度 工作单位 联系电话 听力状况: 母亲姓名 职 业 文化程度 听力状况: 工作单位 联系电话 共同生活的家庭其他成员信息 姓名 性别 与申请人关系 职业 arm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automaticle aland network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operation5 家庭经济状况: 1家庭总人口数 人，家庭年人均收入 元 (家庭年人均收入=上年度家庭总收入?家庭总人口数) 2家庭承担能力 家庭无力承担耳蜗产品之外的任何费用 ? ? 家庭仅有承担耳蜗产品之外调机、设备维护费用 家庭有能力承担耳蜗产品之外其他所有费用 ? 三、病史询问(以下内容由专业人员协助填写) (一)耳鼻咽喉科及口腔科检查情况 耳廓:左耳:正常 ? 畸形 ?; 右耳:正常 ? 畸形 ? 耳道:左耳:正常 ? 畸形 ?; 右耳:正常 ? 畸形 ? 鼓膜:左耳:正常 ? 穿孔 ? 充血?; 右耳:正常 ? 穿孔 ? 充血? 耳科手术史:有 ? 无? ? 无? 唇裂:有 腭裂:有 ? 无? (二)孕产史及生长发育史 母孕期:早孕感染史:有 ? 无 ? 用药史:有 ? 药物名称: 无 ? 长期接触噪声史:有 ? 无 ? 经常桑拿史: 有 ? 无 ? 长期接触有毒物质史:有 ? 无 ? 外伤史 有 ? 无 ? 个人史:足月产 ? 早产 ? 顺产 ? 难产 ? 助产 ? 引产 ? 剖腹产 ? 出生时缺氧 有 ? 无 ? 体重 g 生长发育是否正常 是 ? 否 ? ( ) 既往疾病史:传染病史 有 ? 无 ? 其他疾病史 有 ? 无 ? 遗传性耳聋史:有 ? (与患者关系: ) 无 ? 其它发育障碍:无? 有?(?自闭症 ?智力 ? 视力 ? 肢体 ?其它 ) (三)助听器使用情况 耳聋确诊时间: 是否佩戴助听器:否? 是 ? 配戴耳:左 ? 右 ? 选配年龄: 岁 个月; in system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event record6 助听器配戴时间:<3个月? 3—6个月? 6—12个月? 〉12个月? 助听器类型:模拟机 ? 数码编程机 ? 全数字机 ? 助听器功率:中功率 ? 大功率 ? 特大功率 ? 助听器品牌型号:左耳 ;右耳 (四)目前康复状况及语言能力 ?(康复时间____个月) 家庭训练 ? 未接受康复 ? 患者目前康复方式:机构康复 康复起始时间: 年 月 至 年 月 现在所在康复机构名称: 家长评价申请者目前语言能力:简单交流 ? 能说几个词 ? 无任何语言 ? (五)家庭康复认识及术后期望值 家长是否接受过康复培训: 是 ? 否 ? 家长对手术植入风险和术后康复的重要性的认识:有 ? 无 ? 家长对人工耳蜗植入后的期望值:能听到声音? 能简单交流? 能正常交流? 家庭中是否有专人陪伴康复:有 ? (与儿童的关系 ) 无 ? 四、拟选术后康复机构: 法定监护人签字: 专业人员签字: 日期: 年 月 日 日期: 年 月 日 110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automaticle aland network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics7 五:法定监护人及家庭其他成员户口簿复印件 文件 粘贴处 核对人签字: 核对日期: ove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lov8 六、 法定监护人身份证复印件 (二代身份证正反两面均需复印) 文件 粘贴处 核对人签字: 核对日期: le aland network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automatic9 七、家庭经济收入证明原件 文件 粘贴处 核对人签字: 核对日期: 13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce10 八、行为测听:裸耳和助听听阈测试报告单原件 文件 粘贴处 核对人签字: 核对日期: and network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automaticle al11 九、听性脑干反应(ABR)测试报告单原件(附图) 文件 粘贴处 核对人签字: 核对日期: e automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a op12 十、耳声发射(OAE)测试报告单原件(附图) 文件 粘贴处 核对人签字: 核对日期 le aland network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automatic13 十一、颞骨CT报告单原件(报告中必须描述内耳发育状况) 文件 粘贴处 核对人签字: 核对日期: e automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a op14 十二、颅脑磁共振成像(MRI)报告单原件 文件 粘贴处 核对人签字: 核对日期: le aland network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automatic15 十三、听觉言语能力评估报告 患者姓名: 测试日期: 年 月 日 评估人: 林氏六音觉察阈测试 有察觉反应或能复述均在相应?中打?: m ? a ? u ? I ? sh ? s ? 无察知 ? 听觉整合(父母问卷) (It-mais) 项目 1项 2项 3项 4项 5项 6项 7项 8项 9项 10项 总分 分数 听觉能力评估(封闭项测试) 最大识别率 评估内容 测试记录(正确),(错误) 得分(%) 韵母识别 语 音 识 别 声母识别 双音节词识别 平均识别率得分 言语能力评估(封闭项测试) 评估内容 测试记录 语言年龄(岁) 语法能力 (模仿句长) 理解能力 (听话识图) 交往能力 (主题对话) 平均语言年龄 (岁) 发音水平:发音清晰 ? 能发音 ? 不能发音 ? ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm 16 十四、学习能力及精神行为发育测试报告 患者姓名: 出生日期: 年 月 日 评估日期: 年 月 日 评估机构: 评估人: 测试项 智龄\学习年龄 测试结果 得分 希 穿珠 中位数智龄 , 记颜色 内 辨认图 百分位数 学 联想 习 折纸 能 短记忆力 智商,学习能力商 力 摆方木 测 完成图 验 测试项 智龄(月) 发育商 运动 格雷 费斯 手眼协调 智力 操作 测验 总计 ?说明:以上两项测试根据受试者年龄选做其一 克氏孤独症行为量表得分 Conner多动症评价量表得分 Rutter儿童行为问卷得分 行为观察描述: ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automaticle aland network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside 17 十五、复印件粘贴处: 此页粘贴检查结果复印件，内容如下: 1、裸耳测听报告单复印件 2、助听听阈评估报告单复印件 3、听性脑干反应(ABR)测试报告单复印件(附图) 4、耳声发射(OAE)测试报告单复印件(附图) 5、颞骨CT报告单复印件 6、颅脑磁共振成像(MRI)报告单 7、听觉言语能力评估报告单复印件 8、学习能力及精神行为发育测试报告单复印件 核对人签字: 核对日期: s,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monito18 十六、推荐评分表 听障儿童姓名: 总分: (一)听力评估(满分30分，得分: ) 1、裸耳听力: 纯音测听【好耳】) >90 85—90 <85 (dBHL) 10分 3分 0分 听性脑干反应阈值?100 90—99 <90 (dBnHL ) 10分 5分 0 2、助听听阈评估: ?6 ,6,,3 ,3 未戴 配戴时间 (月) 5分 3分 1分 0 250—1000 250—2000 250—3000 助听补偿范围【好耳】 (Hz) 5分 3分 0分 (二)内耳发育(满分10分，得分: ) 正常 异常(大前庭导水管扩大除外) 内耳发育 10分 0分 (三)、学习能力及精神发育测试(满分15分，得分: ) 1、学习能力及精神发育测试(2择1) 希-内学习能力测试 希-内学习能力测试格雷费斯精神发育格雷费斯精神发育测试 ,84分 ,84分 测试,86分 ,86分 10分 0分 10分 0分 2、三项行为量表: 正常 异常 5分 0分 ?说明:克氏孤独症行为量表、Conner多动症评价量表及Rutter儿童行为问卷三项其中一项 得分异常，判定为异常。 (四)儿童听觉言语康复状况评估(满分20分，得分: ) 1、听觉言语识别能力(满分10分) 3岁以上: 听觉言语平均识别率)【封闭项测试】 20-70 ,20或,70 (%) 分值 10分 0分 3岁以下: U m a i U m a i s Sh 林氏六音察觉阈 六音无反应 任何1个音有反应 六音均有反应 分值 5分 2分 0分 听觉整合问卷(IT-MAIS父母问卷) ,20分 ?20分 分值 5分 0分 ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automaticle aland network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside 19 2、言语能力(满分10分) 年龄?3周岁: 四级(1岁语言年龄水平)及其以上 未达四级(1岁语言年龄水平) 10分 0分 2、年龄,3周岁 模仿发音能力 能模仿 不能模仿 10分 0分 (五)听障儿童术前康复现状(满分5分，得分: ) 在康复机构或接受机在康复机构或接 构康复指导 受机构康复指导 在家里自行康复 未接受任何康复 6个月以上 6个月以下 5分 3分 1分 0分 (六)家庭教育能力评估(满分10分，得分: ) 是 否 家庭中有专人陪伴康复 4分 0分 接受过培训并具有初步未接受过培训并不具有 康复能力 康复能力 家长接受康复培训 3分 0分 能了解、有认识 不了解、无认识 家长对术后康复有正确认 识及适当的期望值 3分 0分 (七)年龄政策(满分10分，得分: ) 1岁以内或5岁1岁—2岁 2岁1个月—3岁 3岁1个月—4岁 4岁1个月—5岁 1个月及以上 10分 8分 6分 2分 0 评分人员签字: 日期: 年 月 日 13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce20 审批意见表 听障儿童姓名 出生日期 年 月 日 推荐总评分 省 残 联 推 荐 意 见 单位盖章: 负责人签字: 日期: 国 家 项 目 专 家 组 审 核 意 见 通过 未通过 未通过原因 终审 意见 ? ? 通过 未通过 未通过原因 定复 点筛 医结 ? ? 院果 备 注 and network resource sharing and remote control, and many other functions, so as to improve the automation of the system. Who ler. Regional alert information is sent to a control center, by the computer control center for data analysis and processing,ontrolion, alarm controller will issue a warning and fault information is displayed; in either case, would give rise to alarm the cd police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit, the illegal situatof any bad hidden an Security Bureau. achieve the rehabilitation centers in agement system has been widely used in the new information security management systems, application access control systems tool manr access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2) access control system access contrtion access control pickup pickup camera detection medical alarm building 3 # number # 3 13 18 cameras total: 203 total numbedetec larm detection access control alarm detection access control pickup pickup camera camera alarm detection access control alarm1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access control pickup pickup camera camera amedical building, rehabilitation building, 2nd floor, serial number F-istics are as follows: security point distribution statistics110 automatic alarm system of network interfaces with local public Security Bureau Monitoring Center security deployment stataside ce, also can set automatically backup alarm records, and automatically delete event records,, do foolproof. Alarm system set ior; in database security aspects, system will automatically check data of integrity, on database for automatically maintenanbehav ally processing; through on operator grading management, can completely control each a operator in system in the of operationarm system can since defined voice report different of alarm State, and can in police love occurred Shi by computer automaticle al21 eratore occurred Shi by computer automatically processing; through on operator grading management, can completely control each a ope automation of the system. Whole alarm system can since defined voice report different of alarm State, and can in police lovove ther for data analysis and processing, and network resource sharing and remote control, and many other functions, so as to imprwould give rise to alarm the controller. Regional alert information is sent to a control center, by the computer control cent, the illegal situation, alarm controller will issue a warning and fault information is displayed; in either case, of any bad hidden and police love. If someone on the line and equipment damage, pry the circuit short circuit or open circuit Bureau. Security pplication access control systems to achieve the rehabilitation centers inss control system access control management system has been widely used in the new information security management systems, a) acce13 18 cameras total: 203 total number access: 52 police discussion Measured quantity total: 72 number of pickups total: 24 (2detection access control alarm detection access control pickup pickup camera detection medical alarm building 3 # number # 3 alarm ontrol pickup pickup camera camera alarm detection access control alarm detection access control pickup pickup camera camera building, 2nd floor, serial number F1 F2 F3 F4 F5 B1 B2 camera camera alarm detection access control alarm detection access cmedical building, rehabilitation -ring Center security deployment statistics are as follows: security point distribution statisticso foolproof. Alarm system set aside 110 automatic alarm system of network interfaces with local public Security Bureau Monitos,, database for automatically maintenance, also can set automatically backup alarm records, and automatically delete event recordin system in the of operation behavior; in database security aspects, system will automatically check data of integrity, on d 22