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
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
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


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