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Hearing Report for the
Newborn Screening Program
FAX completed report to MDH at 651-215-6285
* Please be sure to send a copy of any results to the child's primary care provider.
Child's Name: Last:
First:
Address:
DOB:
City:
Child's Health Insurance:
Private
Phone:
Self Pay
MN Public
Parent/Guardian Name: Last:
ZIP:
Other
First:
Alt. Phone:
Unknown
Relationship:
Language Used in Home:
Clinic:
Screener:
Complete the section(s) appropriate for your evaluation . Do NOT delay diagnostic referral solely due to middle ear dysfunction!
New Appt. Date:
APPOINTMENT CHANGE: Date:
Family did not show
Family cancelled
Reason No Appt. Made:
SCREENING RESULTS: Date:
Right Ear:
Pass
Refer
Left Ear:
Pass
Refer
Important: Screen both ears
Technology Used:
OAE
AABR
**If result is a REFER for one or both ears, schedule a diagnostic appointment as soon as possible!
DIAGNOSTIC REFERRAL: Refer for diagnostic evaluation immediately for timely diagnosis!
Referral to Audiology Made:
Yes
No
Date of Appointment:
Clinic:
Audiologist:
Any Additional Comments:
Newborn Screening Program
P.O. Box 64899, St. Paul, MN 55164-0899
FAX: (651) 215-6285; Phone: (651) 201-5466 or (800) 664-7772,
www.health.state.mn.us/newbornscreening
08/11