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Outpatient Hearing Screening Form Early Hearing Detection and Intervention Program FAX (517) 335-8036 (Send hearing screen card to MDCH) Newborn Information Newborn's Name: Date of Birth: Hospital.

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How to fill out the Content Of Screening Form online

Completing the Content Of Screening Form online is an important process for ensuring the health and well-being of newborns. This guide will provide you with clear, step-by-step instructions to help you accurately fill out the necessary information.

Follow the steps to successfully complete the Content Of Screening Form.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Begin by entering the newborn's name in the designated field. Select their gender by checking either 'Male' or 'Female' and indicate if the newborn is a twin by selecting from 'A', 'B', or 'C.'
  3. Fill in the hospital of birth and the initial screen date. Ensure that the date format is correct. Select the method of screening by marking either 'A-ABR,' 'OAE,' or 'ABR.'
  4. Record the date of birth and the kit number. Check the results for the right and left ears, marking 'Pass' or 'Refer' as applicable.
  5. Complete the medical record number section with the appropriate identification number.
  6. Provide parent or guardian contact information by filling in the mother's name, address, phone number, and an alternate contact's name, address, and phone details.
  7. In the referral information section, indicate if a referral to the primary care physician is needed. Fill out their name and phone number, and provide details for any outpatient re-screening, including site name and scheduled date.
  8. Document outpatient screen results by entering the date and method. Mark the results for both ears as 'Pass' or 'Refer' as needed. Include the diagnostic site name.
  9. Make sure to provide parental or guardian permission by signing the required section and including the date of the signature.
  10. Once all fields are complete, review the information for accuracy. Then you can save changes, download, print, or share the form as needed.

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