of
The Children’s Hospital
Philadelphia
NAME:
SEX:
M
F
MR#:
Cochlear Implant Program
Children’s Implant Profile (ChIP - modified)
AGE/DATE OF BIRTH:
ACCT#:
 Inpatient  Center for Childhood Communication-Main
 Specialty Care Center-____________________________
__
Cochlear Implant Program
Children’s Implant Profile (ChIP - modified)
________
Date of Team Review:
Date(s) of Evaluations:________________________________
Etiology of Hearing loss:
Age at Onset of Hearing Loss:
________________
Communication Mode:
School Placement:
_
TEAM IMPRESSIONS OF THE FACTORS IMPORTANT
TO IMPLANT USE AND SUCCESS
1. CHRONOLOGICAL AGE
2. DURATION OF DEAFNESS
3. OTOLARYNGOLOGY

Medical

Radiological
4. OTHER DISABILITIES
5. AUDIOLOGY

Test Reliability

Hearing Aid Use

Hearing Aid Benefit
6. SPEECH PATHOLOGY

Auditory Training

Formal Language Use/Comprehension

Use of Voice to Communicate

Desire to Communicate
7. SOCIAL WORK

Family Structure & Support

Child’s Behavior

Expectations (Parents)

Expectations (Child)
8. EDUCATION

Current Educational Placement

Future Educational Placement(Transition)

Access to Auditory-Oral Services

Educational Staff CI Training 

Ability of Parent to Participate in Educational Process
NO
CONCERN
SOME
CONCERN
GREAT
CONCERN
Team Concerns:
Recommendations:
Date Discussed with Family:
Audiologist Signature
____________________________________
Audiologist Name (PRINT)
Modified ChIP Guidelines – Rev. 01/04
FACTORS IMPORTANT TO IMPLANT USE
& SUCCESS
1. CHRONOLOGICAL AGE
2. DURATION OF DEAFNESS
3. OTOLARYNGOLOGY

Medical

Radiological
4. OTHER DISABILITIES
5. AUDIOLOGY

Test Reliability

Hearing Aid Use

Hearing Aid Benefit
6. SPEECH PATHOLOGY

Auditory Training

Formal Language Use/Comprehension

Use of Voice

Desire to Communicate
7. SOCIAL WORK

Family Structure & Support
NO CONCERN
SOME CONCERN
< 2 years
< 2 years
> 2 years but < 6 years
> 2 years but < 6 years
> 6years
> 6years
Good general health
Seizure or reactive airway
disorders
Partially ossified or not
completely formed
Blindness; oral motor disorder;
sensory integration issues;
learning differences;
ADD/ADHD
Airway disorder or cardiac issues
Good test reliability
History of consistent hearing aid
use
Little or no functional hearing aid
benefit
Fair test reliability
Limited hearing aid use
(> 50%)
Some functional hearing aid
benefit
Poor test reliability
No history of consistent use
(< 50%)
Excellent functional hearing aid
benefit
Consistent auditory training &
conditioned response
Comprehension & expression of
spoken language emerging or
used
Consistently uses voice alone or
paired with sign language
Age appropriate attempts to
communicate regardless of
language form used
Limited auditory training&
minimal response
Communicates via sign language
only
No auditory training
Requires occasional cues to
voice
Moderate therapist intervention
needed to engage child in ageappropriate communication turntaking
Absent use of voice without
maximum cueing
Maximum therapist intervention
needed to elicit appropriate
attention/communication from
child
Family communicates with child
effectively; actively involved in
child’s therapy & educational
program; effectively coping with
parental stress
Family does not communicate with
child effectively; non-intact family
with issues that override child’s
needs; severe parental stress; past
history of noncompliance with
medical regimens
Severely hyperactive, aggressive or
defiant behavior; poor parental
control of child’s behavior;
consistent disengagement in
therapy sessions
Believe CI will restore normal
hearing; family has no plan for
rehab
Cochleas are normal & patent
No disabilities other than deafness

Child’s Behavior
Behavior problems typical for
age; effective parental control of
behavior
Some family members
communicate with child
effectively; moderate parental
stress; occasional canceled or
broken appt. during eval or by
history
Sporadic parental control of
child’s behavior; inconsistent
engagement in therapy sessions

Expectations (Parents)

Expectations (Child)
Realizes CI will not restore
normal hearing; parental
agreement about implant; family
has plan for rehabilitation
Realizes CI not corrective & will
need therapy
Believe child will move to a
mainstream setting with no
support services; expectations
are inflexible; reliability
Believes will not need help
using the CI; reliability
Auditory oral class or oral Ms;
true TC program; appropriate Ed.
Environment
Auditory oral class or oral Ms;
true TC program; appropriate Ed.
Environment
Program provides strong AVT,
SLP or hearing Tx service
(> 3/wk or AVT available)
Teachers & therapist trained to
work with CI (NECCI & other
workshops; experience w/CI
Parents appear to understand
educational system, IDEA, etc.
Strong advocacy skills
TC with limited auditory oral
emphasis; special ed; limited
individual auditory Tx
TC with limited auditory-oral
emphasis; special ed.; limited
individual auditory Tx
Program will provide moderate
levels of AVT, SLP or hearing
Tx service (2x/wk)
Teacher & therapist with limited
training or CI experience
8. EDUCATION

Current Educational Placement
Ms = mainstream

Future Educational Placement

Access to Auditory-Oral Services

Educational Staff CI Training

Ability of Parents to participate in
Educational Program
GREAT CONCERN
Parent has beginning knowledge
of educational system, IDEA,
etc. Potential advocacy skills
Completely ossified or severely
malformed
Global developmental delay;
Autistic Spectrum Disorder; 2 or
more mild/moderate handicapping
conditions
No formal lang. system in place
Believes CI will restore normal
hearing
ASL hearing impaired self –
contained class; no auditory Tx
ASL hearing impaired selfcontained class; no auditory Tx
Program will provide minimal of
AVT, SLP or hearing Tx services
(1x/wk)
Teacher or therapist have no CI
training or experience with CI
training
Parent has little understanding of
educational system, IDEA, etc.
Appears to have poor advocacy
skills