1- 3- 6 NEWBORN HEARING SCREENING
CHECKLIST
Patient Name: _______________________________________ Patient DOB: _____________ Date of Visit: ___________
1
INITIAL SCREENING
(by no later than 1 month of age)
Has the child had a newborn hearing screening?
Yes
No
Schedule initial screening
Did you obtain the test results from the screening hospital
Contact the hospital or state EHDI program
Yes
No
or state EHDI program?
Are the results recorded in the patient’s chart?
Yes
No
Record test results in patient chart
Did the child pass the newborn hearing screening?
Yes
Schedule rescreening appointment
No
Have the results been reported to the state EHDI program?
Yes
No
Confirm results have been reported to state EHDI
program within 48 hours of receiving them
Have results been discussed with family?
Yes
For a child who passed, stress the importance
No
of ongoing surveillance and risk factors*
For a child who did not pass, discuss the
need for follow-up and assist in arranging a
rescreening
Has a rescreening occurred (if the initial screen resulted in
Yes
Schedule rescreening appointment
No
“did not pass” or if otherwise necessary)?
RESCREENING
(by no later than 1 month of age)
Where will the rescreening be performed?
Hospital: ______________________________________________
If hospital/outpatient center, when is the rescreening
Office
appointment?
Other (specify): ________________________________________
If conducted in office:
• Determine what screening equipment was used at the
hospital.
Location: ________________________________________________
• Follow the AAP office rescreening guidelines.
Date: ___________________________________________________
Did the child pass the rescreening?
Yes
No Send child to audiologist with pediatric expertise for
diagnostic evaluation.
Are the results recorded in the patient chart?
Yes
No Record results in patient chart.
Have the results been discussed with the family?
Yes
No For a child who passed, stress the importance of
ongoing surveillance and risk factors*
For a child who did not pass, discuss the need
for follow-up and assist in arranging an
audiologic evaluation
Have the results been reported?
Yes
No Confirm results have been reported to state EHDI
program within 48 hours of receipt