Newborn Hearing Screening Results

Baby’s Name: Date of Birth: Hospital or location of baby’s birth: Screening agency or site where this test was completed: Agency: Address: Screener: Phone: Initial Screening Follow-up Screening Technology: TEOAE DPOAE AABR ABR Date of Testing: Screening Results: Right Ear: PASS REFER Left Ear: PASS REFER Recommendations: Referred to: Date: Parent or Guardian Contact Information: Name: Address: Phone: Baby’s Primary Care Provider: Name : Phone: