Newborn Hearing Screening Report Form
Document the results and follow-up details of a newborn hearing screening.
Newborn's First Name
*
Newborn's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Screening Method
*
Please Select
Otoacoustic Emissions (OAE)
Automated Auditory Brainstem Response (AABR)
Other
Screening Result
*
Pass
Refer
Inconclusive
Ear(s) Tested
*
Left
Right
Both
Follow-up Recommendation
*
Please Select
No further action needed
Repeat screening
Refer to audiologist
Other
Provider Name
*
Provider Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Report
Should be Empty: