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Diagnostic Hearing Evalutation Forms

The eDiagnostic Hearing Evaluation Form for audiological evaluation results on infants or toddlers up to 36 months of age is available in two versions. The eDiagnostic Hearing Evaluation Form can be completed on the computer, printed, signed, and then faxed. The Diagnostic Hearing Evaluation Form can be printed, completed by hand, and then faxed. This form also contains directions on obtaining a free hearing aid test kit and submitting results to the newborn screening data system.

Screening Forms

If newborn hearing screening results are not reported using the Florida Newborn Screening Metabolic Specimen Collection Card, one of three different hearing screening forms must be submitted for initial and follow-up hearing screenings. The eHearing Screen Form for Single Result or the eHearing Screen Form for Multiple Results can be completed on the computer and then sent preferably via Direct Secure Messaging (DSM), or printed and then faxed to (850) 245-4049. The Hearing Screen Form can be printed, completed by hand, and then scanned and sent preferably via DSM or faxed. See the Standard Operating Procedure for Updating and Using DSM for questions about DSM.