Hearing Screening Referral Form

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HEARING SCREENING FORM
EARLY HEARING DETECTION AND INTERVENTION PROGRAM
FAX (517) 335-8036
(Send Hearing Screen Card to EHDI)
N
I
EWBORN
NFORMATION
Newborn’s Name: ____________________________________
Male
Female
Twin:
A
B
C
Hospital of Birth: _____________________________________
Initial Screen Date: ____________________
Method:
A-ABR
OAE
ABR
Date of Birth: __________________ Kit #_________________
Results: Right Ear:
Pass
Refer
Left Ear:
Pass
Refer
Medical Record #:————————————————————-
P
/G
C
I
ARENT
UARDIAN
ONTACT
NFORMATION
Mother’s Name: ______________________________________________________________________
Address: ____________________________________________________________________________
Phone #: (______)______________________
Alternate #: (______)______________________
Alternate Contact (Friend/relative/case worker/adoption agency
Name: _____________________________________________________________________________
Address: ___________________________________________________________________________
Phone #: (______)______________________
Alternate #: (______)______________________
R
I
EFERRAL
NFORMATION
Referral to primary care physician for follow-up
Name: ______________________________________
Phone #: (________)____________________
Referral for outpatient re-screening? Site name: _____________________________________________
Phone #: (________)____________________
Date Scheduled: _______________________________
O
S
R
UTPATIENT
CREEN
ESULTS
Date:
Method:
A-ABR
DPOAE
ABR
Date diagnostic hearing evaluation scheduled:
Results: Right Ear:
Pass
Refer
Diagnostic Site Name:_____________________________________
Left Ear:
Pass
Refer
P
/G
P
ARENTAL
UARDIAN
ERMISSION
I give my permission to release referral results to my primary care physician and the Michigan Department of Health and Human
Services Early Hearing Detection and Intervention (EHDI) Program. EHDI also has my permission to assist with coordination of fol-
low-up on behalf of my child. Information will not be shared with unauthorized people or agencies not involved in hearing screening
follow-up.
Signature of Parent/Guardian: ____________________________________Date: __________________
Updated 05/15/2015

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