1-3-6 Newborn Hearing Screening Checklist - Public Health Division Page 2
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DIAGNOSTIC EVALUATION
(by no later than 3 months of age)
If the child did not pass the rescreening, was he/she
Yes
No Refer to
referred to an audiologist with expertise in pediatrics?
audiologist
Provider: ______________________________
with
expertise in
Date of Visit: ___________________________
pediatrics
Were the results of the diagnostic test normal?
Yes
No Discuss early intervention (EI) and need for
comprehensive plan
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 EI and
need for comprehensive plan
Have the results been reported?
Yes
No Confirm results have been reported back to state
EHDI program within 48 hours of receipt
6
EARLY INTERVENTION
(by no later than 6 months of age)
If the child was diagnosed with a hearing loss, was he/
Yes
No Provide referral for EI,
she referred for early intervention and multidisciplinary
ophthalmology, and
Date of visit: ________________
evaluation?
otolaryngology and offer
referral for genetics
ONGOING SURVEILLANCE AND SCREENING
Continue to perform ongoing surveillance and screening for late-onset hearing loss, particularly children with risk factors.
*JCIH Risk Factors
A program of the American Academy of Pediatrics in cooperation with the Centers for Disease Control & Prevention
a program to enhance the health & development of infants & children
Funding for the development of these materials was provided through a cooperative agreement
Early Hearing Detection
(U43MC09134) between the American Academy of Pediatrics and the US Department
of Health and Human Services, Health Resources and Services Administration, Maternal
& Intervention Program
and Child Health Bureau as well as through a cooperative agreement (5U58DD00587)
between the American Academy of Pediatrics and the National Center on Birth Defects and
Developmental Disabilities of the Centers for Disease Control and Prevention (CDC). Content
is solely the responsibility of the authors and does not necessarily represent the official views of
A program of the American Academy of Pediatrics in cooperation with the
the Maternal and Child Health Bureau or the Centers for Disease Control and Prevention.
Centers for Disease Control & Prevention and Maternal & Child Health Bureau/HRSA
April 2014
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