Illinois Department Of Public Health Newborn Hearing Screening Audioloortgy Follow Up Services Rep Page 2

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AUDIOLOGY FOLLOW-UP SERVICES REPORT (cont.)
CHILD’S NAME:
____________________________
Med.ID:
____________________
RECOMMENDATIONS / REFERALS
DATE REFERRED
Pass with High Risk Monitoring ____ 3mo. _____ 6mo. ____ 1Yr
Early Intervention Services (EI)
Division of Specialized Care for Children (DSCC)
Medical Referral (to whom?)
Repeat Diagnostic Hearing Testing (date scheduled?)
Hearing Instrument Fitting
None
Other: (Specify)
(Mark all that apply):
SCREENING TOOL:
DIAGNOSTIC TESTS:
DPOAE: ________
Physical exam, review of medical records __________
TEOAE: _________
DPOAE __________ TEOAE_________
Automated ABR _________
ABR __________
Other:(specify) ____________________________________________________________
NOTES: __________________________________________________________________________________________
_________________________________________________________________________________________________
Audiologist: (full name) _______________________________________________________________________________________
Facility / Agency: _____________________________________________________________________________________________
____________________________________________________________________________________________________________
Address
City
State
Zip
Phone: (______) ______________________________
Fax: (______) ____________________________
Infant’s Primary Health Care Provider: ____________________________________________________________________________
____________________________________________________________________________________________________________
Address
City
State
Zip
Phone: (______) _______________________________
Fax: (______) ____________________________
Please submit BOTH PAGES of this form to:
Illinois Department of Public Health
Newborn Hearing Screening Program
rd
535 West Jefferson, 3
floor
Springfield, Illinois 62761
217-782-4733
The form may be faxed to: 217-557-5324
Email: DPH.newbornhearing@illinois.gov

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