Early Hearing Detection And Intervention (Ehdi) Hearing Screening Follow-Up Report
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1State of Illinois
Illinois Department of Public Health
Early Hearing Detection and Intervention (EHDI)
Hearing Screening Follow-up Report
Please Print
Child’s Name __________________________________________________________ Med. ID ______________________
Other names this infant may also be known as:
___________________________________________________________________________________________________
Date of Birth ____________________________________ Sex:
Male
Female
Birth Hospital ________________________________________________________________________________________
Mother/Guardian Name ________________________________________________________________________________
(Last)
(First)
(MI)
Address ____________________________________________________________________________________________
(Street)
(Apt.#)
___________________________________________________________________________________________________
(City)
(State)
(ZIP)
(County)
(Phone)
Physician’s FULL Name________________________________________________________________________________
Phone ________________________________________ FAX _______________________________________________
Screener’s Name &Title
_____________________________________________________________________________
Address
____________________________________________________________________________________________
Phone ________________________________________ Date Completed ______________________________________
PER THE JOINT COMMITTEE ON INFANT HEARING: TESTING OF BOTH EARS SHOULD BE COMPLETED ON THE SAME DAY
DPOAE
Automated ABR
TEOAE
Screening Technology Used:
Screening Results:
Right Ear Result
Pass
Refer
Left Ear Result
Pass
Refer
Notes / Action plan:
Illinois Department of Public Health
This form may be faxed to: 217-557-5324
Early Hearing Detection and Intervention
OR
535 W. Jefferson St., 2nd floor
Springfield, IL 62761
E-mailed to: dph hearingreports@illinois gov
217-782-4733
IOCI 14-342
1/15
Printed by Authority of the State of Illinois
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