Family Decline Hearing Screening

I/we:

Name of Parent/Guardian

the parent/guardian of:

Newborn's Name

born on:

Date of Birth

at name of birth hospital or birthing midwife:

Hospital or name of home birth midwife

, decline the newborn hearing screening for our baby.

Primary Care Provider/Practice:

Primary Care Provider/Practice

Please check the reason below:

Family phone number:

Please enter a valid phone number.Format: (000) 000-0000.

Family alternate phone number:

Please enter a valid phone number.Format: (000) 000-0000.

Name of midwife:

Family phone number:

Please enter a valid phone number.Format: (000) 000-0000.

Family alternate phone number:

Please enter a valid phone number.Format: (000) 000-0000.

I/we have been informed and provided with written information about what the hearing screening procedure involves.

I/we have had the opportunity to discuss newborn hearing screening with our baby's doctor, the hospital staff, or other care provider, and all our questions have been answered to our satisfaction.

I/we further understand that if our baby does have hearing loss and is not identified in the newborn period the risk that our child could have delays in language and learning as well as other health problems associated with conditions that include hearing loss are possible.

I/we acknowledge that this form will be filed in our baby's medical record, and copies will be sent to our baby's care provider and the Vermont Department of Health Early Hearing Detection and Intervention Program.

Signature of parent/guardian:

Date:

Date

Signature of witness:

Date:

Date

Instructions:

1. This form must be completed for all newborns when the parent/guardian(s) decline newborn hearing screening prior to discharge for any reason.

2. The original signed copy must be filed/documented in the infant's medical records at your facility.

3. Faxed the signed form to the baby's primary care provider and to the Vermont Early Hearing Detection and Intervention (VTEHDI) Program (802) 951-1218. www.healthvermont.gov/hearing