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Enter Hospital Name Here NEWBORN HEARING SCREENING Infant Reporting Form INPATIENT IP SCREEN COMPLETED IP Screening RIGHT LEFT EAR DATE OF SCREENING ABR ABR-Auditory Brainstem Response DPOAE TEOAE PASS REFER RESULT check one DPOAE-Distortion Product Otoacoustic Emission TEOAE-Transient Evoked Otoacoustic Emission Transferred out to Hospital Name Unit on date Missed discharged without screen Complete Follow-Up section below Waived Face Sheet not r.

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