Get Mi Hearing Screening Form 2021-2025

The MI Hearing Screening Form is an essential document used to assess the hearing capabilities of newborns. This guide provides step-by-step instructions on how to complete the form online, ensuring a smooth and efficient process for users.

Follow the steps to fill out the MI Hearing Screening Form online

1. To begin, click the ‘Get Form’ button to access the MI Hearing Screening Form and open it in your preferred editing tool.
2. In the 'Newborn Information' section, fill in the newborn’s name, the hospital of birth, the date of birth, and the kit number. Select the gender of the newborn, and if applicable, indicate if the newborn is part of a set of twins.
3. Indicate the date of the initial screening, the method used (select one from A-ABR, ABR, or OAE), and enter the results for the right and left ears by selecting either 'Pass' or 'Refer'.
4. Provide the medical record number in the designated field.
5. In the 'Parent/Guardian Contact Information' section, complete the details for the parent or guardian, including the mother’s name, address, and both phone and alternate contact numbers.
6. Fill out the alternate contact information for a friend, relative, case worker, or adoption agency, including their name, address, and phone numbers.
7. Under 'Referral Information', indicate if a referral to a primary care physician is needed and provide their name and phone number if applicable. Also, indicate if a referral for outpatient re-screening is required, along with the site name and phone number.
8. Fill in the scheduled date for the outpatient screen and any results that may apply under the 'Outpatient Screen Results' section, specifying the method used and results for both ears.
9. Complete the section for the scheduled date of the diagnostic hearing evaluation and the name of the diagnostic site.
10. Finally, provide parental or guardian permission by signing and dating the form in the specified area. Ensure you understand that the information shared will be kept confidential.
11. Once all sections are completed, save any changes made to the form, and choose to download, print, or share the completed MI Hearing Screening Form as needed.

Complete the MI Hearing Screening Form online today to ensure comprehensive hearing assessment for your newborn.