was either unsatisfactory for testing or showed an abnormal result.

Should you choose to have your baby screened but do not want Vermont Newborn Screening Program to retain the blood sample for one year, there is the option to have it destroyed sooner. Please see the Vermont Newborn Screening Program's website for the required form: healthvermont.gov/family/newbornscreening

~I/we have been provided with the Vermont Newborn Screening brochure and have reviewed the screened conditions.

~I/we have had the opportunity to discuss newborn 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 feel that we have all the information necessary and have made the decision not to have repeat newborn screening for our baby and do not wish to discuss newborn screening further with newborn screening staff, our baby's doctor, or other care providers who are available to answer related questions.

~I/we further understand that if our baby does have a newborn screening condition, and it is not identified in the newborn period, the risk of death, disability, and illness may be high.

~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 Newborn Screening Program.

Instructions:

1. This form must be completed when the parent/guardian(s) decline to have a repeat newborn screening test for their baby.

2. The original signed copy must be filed/documented in the baby's medical records.

3. If unable to complete this form electronically, please fax the signed form to the Vermont Newborn Screening Program at (802) 951-1218 or mail it to 280 State Drive, Waterbury, VT 05671-8360. Please call (802) 951-5180 with questions.

 

Newborn Screening Declination Form (Repeat), Rev 2/26/24