ALI YAVAR JUNG NATIONAL INSTITUTE FOR THE HEARING HANDICAPPED K.C. Marg, Bandra Reclamation, Bandra (w), Mumbai-400050. (Department of Empowerment of Persons with Disabilities, Ministry of Social Justice and Empowerment, Government of India, New Delhi) FITMENT OF COCHLEAR IMPLANT UNDER REVISED ADIP SCHEME (2015-16) APPLICATION FORM The forms can be filled online and submit with all details. Alternatively a hard copy of the blank form can be taken, fill up and send with all required supporting documents to – Director, Ali Yavar Jung National Institute for the Hearing Handicapped, K.C. Marg, Bandra Reclamation, Bandra (w), Mumbai-400050 superscribing ‘Application for ADIP Cochlear Implant Service’. Application with incomplete information will not be considered. DETAILS OF THE CHILD Name : Affix Child ‘s Photo Date of Birth : Age : Gender : Male Degree of Hearing Loss : Mild Type of Hearing Loss : Conductive Female Moderate Transgender Moderately Severe Mixed Severe Profound Sensorineural PARENT'S INFORMATION (Fill care giver’s details if applicable & indicate in remark) Father’s Details Name : Age : Religion : Category : Educational Qualification Profession : : General ST OBC NT Mother’s Details SC General ST OBC NT SC Permanent Address : Address for Communication (With pin code) : : Residence number : Mobile number Annual income (Rs.) : : AADHAAR Card No. : Monthly/Annual Monthly/Annual Remark : FAMILY DETAILS Family Set Up : No. of siblings : Brothers : Joint Nuclear Sisters : Any person with disability in the family? YES/NO If yes, give details : Any person in the family with cochlear implant? YES/NO If yes, give details : DETAILS ABOUT HEARING AND SPEECH STATUS OF THE CHILD Has your child's hearing testing been done? : Yes No Is your child using hearing aids? : Yes No If yes, give following details : Which ear? : Right Left Name of the hearing aid: Since when : For how many hours each day? : Does your child have a cochlear implant? : Is your child's speech-language assessment done? : Yes No Yes No Both Is your child attending speech therapy? : Yes No If yes, give following details : Name of the Center : Since when : How many times per week? : Is your child's psychological assessment done? Yes No Has your child been seen by any other medical specialist (e.g. ENT, Neurologist, Pediatrician, etc.)? Has your child been investigated radiologically for cochlear implantation (CT/MRI)? Yes No Yes No Is your child attending Early Intervention/Preschool/School? Yes No If yes, give following details : Name of the School : Type Of School : Class : Since when : How many hours per week? Does your child have problem other than hearing loss (e.g. mental retardation, autism, cerebral palsy, visual impairment, hyperactivity, etc.)? Yes No Mandatory documents to be attached along with the Application : (All diagnostic reports must be from an authorized/registered professional only) 1. 2. 3. 4. 5. 6. 7. 8. 9. Birth Certificate of the child. Caste Certificate of the Father. Income certificate of family including both parents /care givers. Hearing evaluation reports (Audiogram/ABR/IA/OAE/Other). Speech & Language Evaluation Report. Psychological Evaluation Report. Medical evaluation report (ENT/Neurologist/Pediatrician/Registered Medical Professional) Radiological evaluation ( Printed report of CT/MRI) Reports of other evaluations I have read the ADIP Scheme and abide by ADIP scheme, Guidelines of CI and Corrigendum. Signature of Parent/Guardian Place : Date : Name :