Fillable Diagnostic Hearing Evaluation Form (Page 2 of 2) in pdf

Children’s Medical Services (CMS) - Newborn Screening Program

Instructions for completing the Diagnostic Hearing Evaluation form

Please complete and submit this form for each visit for all infants and toddlers (birth to three) WITHIN 2 DAYS OF THE APPT.:



With CONFIRMED OR SUSPECTED permanent hearing loss; or



With evidence of auditory neuropathy/dys-synchrony in one or both ears; or



Who did not pass their newborn hearing screening, regardless of the evaluation results

This form is intended to collect the results of a single visit. Please record only the extent of loss noted during this

visit, and use additional forms to record subsequent visits.

Release of Protected Health Information without Authorization

–

Children’s Medical Services, a division of the Florida

Department of Health, administers the Newborn Screening Program, which includes hearing and metabolic screening. Newborn screening is an

activity described in its capacity as a public health authority as defined by the HIPAA Standards for Privacy of Individually Identifiable Health

Information, Final Rule (Privacy Rule). Pursuant to 45 CFR 164.512(b) of the Privacy Rule, covered entities such as your organization may disclose

protected health information (PHI) to public health authorities without individual authorization. Public health entities are authorized to collect or

receive such information for the purpose of preventing or controlling disease, injury, or disability including, but not limited to, the reporting of

disease, injury, vital events such as birth or death, and for the purpose of conducting public health surveillance, public health investigations, and

public heath intervention. For more information, visit the Center for Disease Control and Prevention site:

Demographic Information

For the child’s first visit to your facility, please complete all asterisked (*) demographic information to ensure that CMS Newborn Screening has a

complete record.

Audiological Evaluation Results

Level 1 – Diagnostic evaluation results from this visit – Please indicate the type of test(s) performed and the results for each test.

Level 2 –Type and degree of hearing loss suspected (S) or confirmed (C) during this visit– Please indicate whether hearing loss is S

USPECTED

(S) or C

(C) in the appropriate box(es). Referral to CMS Early Steps is required by Federal Law [34 CFR, § 303.303(a)(2)(i)] for any

ONFIRMED

child with a confirmed permanent hearing loss. The diagnosing audiologist must refer an infant/family to the local early intervention program as

soon as possible but in no case more than seven calendar days after identification of hearing loss. Do not wait for full threshold information.

Referral and Follow-Up Information

Overall Hearing Status – Select a single option that best represents the hearing status determined at the close of this visit. Please use the comment

section to provide further information as appropriate.

Hearing Risk Status – Please check all risk factors that apply. Family history refers to a blood relative (e.g. grandparent, parent, aunt, uncle, first

cousin, siblings) with permanent hearing loss in early childhood. PPHN refers to persistent pulmonary hypertension of the newborn.

ECMO refers to extracorporeal membrane oxygenation. NICU refers to the newborn intensive care unit of a hospital.

Comments – Please indicate if this is a child who passed newborn hearing screening and is later being identified with permanent hearing loss,

presence of syndromes or known etiologies, if child is already receiving early intervention services, date of further confirmatory hearing testing,

etcetera.

Request a Free Hearing Aid Test Kit –

When requested, a free hearing aid test kit for the child will be sent to the requesting audiologist from

CMS Newborn Screening Program. The “Primary Language of the Family” must be indicated on the form so that the appropriate instruction sheet can

be included.

Please note that in order to receive a free kit:



The child must be referred to a local Early Steps;



CMS Newborn Screening Program must have received this form;



The space next to “I request a hearing aid listening test kit…” must be checked; and



The child must be under three years of age.

For more information regarding Florida’s newborn screening program, referral, or diagnostic follow up services contact Newborn

Screening Program at (850) 245-4201 or (866) 289-2037 or refer to

For more information about CMS-approved audiologists or services through Early Steps for families of children with hearing loss contact Newborn

Screening Program at (866)289-2037 or visit

Diagnostic Hearing Evaluation Form Page 2

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