NDCPD - North Dakota Early Hearing Detection and Intervention

ND EHDI Online Reporting Form

Please enter contact information of the PERSON FILLING OUT FORM

Name (last, first): Agency:

Phone Number: E-mail Address:

PATIENT Information

Child's name:     Gender

Birth Hospital:     Child's Medicaid #:

Mother's Name:     Father's Name:

Home Address:     City:     State:     Zip:

Mother's Phone:

Primary Physician:

Facility Name: Physician Phone:

Hearing Screening Information First Screen Second Screen

Testing Technique    ABR    DPOAE    TOAE

Technology used (device name):     Screen Date:

Facility:     Phone Number:

Right Ear Results           Left Ear Results

Referral made to Right Track:

Parent Infant Program (PIP):

Infant Development Program (Part C):

Diagnostic Testing Information

Testing Date      Audiologist      Phone Number

Testing Technique
     Additional Technique Info

Right Ear Results     Technology Used     Type     Degree

Left Ear Results       Technology Used     Type     Degree

ENT Information

ENT appointment required?

ENT Appointment Date        ENT Physician

Genetics referral?         Genetics Appointment Date

Genetics Physician

Early Intervention Services

Referral made to Right Track:

Parent Infant Program (PIP):

Infant Development Program (Part C):

Amplification / Intervention Data

Right Ear     Date of hearing loss confirmation Fitting Date

                   Style:

Left Ear       Date of hearing loss confirmation Fitting Date

                   Style:

Additional Information / Notes:

Additional Information / Notes