NDCPD - North Dakota Early Hearing Detection and Intervention

Hearing Screen ONLINE Reporting Form

Please enter contact information of the PERSON FILLING OUT FORM

Name: Agency:

Phone Number: E-mail Address:

Patient Information

Child's name (Last, First, MI): Gender:

DOB:

Place of Birth: Home Hospital (name):

Primary Care Physician

Risk Factors: Ototoxis meds NICU >5 days Cranio-anomaly Other

Mother/Guardian Information

Mother's Name: Father's Name:

Home Address (City, State, Zip): Parent Phone:

Hearing Screen Results

Screening Location: Initial Birth Screen Outpatient Follow-up Screen

Date of Screening:

Device Type (Accuscreen, AuDX, Euroscreen, Algo, etc.):

Technology Used: DPOAE TOAE AABR

Left Ear Results: Pass Refer Not Screened (list reason):

Right Ear Results: Pass Refer Not Screened (list reason):

Screen performed by:

Screen has made Early Intervention/Primary Care Physician referral(s) to:
No referral made Right Track Parent Infant Program Infant Development (Part C) Primary Care Physician

Additional Information/Notes:

Additional Information / Notes