Newborn Hearing Screening Results Form - Utah Department Of Health printable pdf download

Newborn Hearing Screening Results Form - Utah Department Of Health

Newborn Hearing Screening Results

Baby’s Name: _________________________________

Date of Birth: __________________________

Hospital or location of baby’s birth: _____________________________________________________________

Screening agency or site where this test was completed:

Agency: ____________________________________ Address: ___________________________________

Screener: ____________________________________ Phone: _____________________________________

______Initial Screening

______Follow-up Screening

Technology: _______ TEOAE _______ DPOAE _______ AABR

_______ABR

Date of Testing: _______________________________

Screening Results:

Right Ear: _______ PASS

_______ REFER

Left Ear: _______ PASS

_______ REFER

Recommendations: ___________________________________________________________________________

Referred to: ____________________________________________ Date: _______________________________

Parent or Guardian Contact Information:

Name: __________________________________Address:_____________________________________

Phone: __________________________________

____________________________________

Baby’s Primary Care Provider:

Name : __________________________________Phone: ____________________________________

I hereby give my permission to staff at the above-named agency or site to release hearing screening results to the hospital where my baby

was born and to the Utah Department of Health. I understand that newborn hearing screening is required by law, and must be reported to the

Utah Department of Health. The information will be used to ensure that appropriate referral and follow-up services, when necessary,

are made available to my child. I understand that this information will not be shared with unauthorized people.

____________________________________________________________

Signature of Parent

Date

To the screening agency:

Please complete this entire form and return copies to the birthing hospital listed, in care of the Newborn Nursery Hearing

Screening Coordinator, AND to the:

Fax: (801) 584-8492

Utah Department of Health

Hearing, Speech & Vision Services

Box 144620

Salt Lake City, UT 84114-4620

Phone: (801) 584-8215

DISTRIBUTION: Yellow: Parent, White: Utah Department of Health, Blue: Birthing Hospital, Pink: Infant’s Medical Record

08/2009

Newborn Hearing Screening Results Form - Utah Department Of Health