EHDI Forms

Forms included on this page are meant to be a resource to support newborn hearing screening and follow-up. Information submitted to the EHDI program shall be submitted electronically through the EHDI database. Please contact EHDI staff with questions.

Early ACCESS Referral Form

This form should be used to refer children diagnosed with hearing loss to early intervention services. This can also now be done through the new database system.

• Early ACCESS referral form

Screening and Diagnosis Reporting Forms

These forms should only be used until access to the EHDI database is granted. All reporting should be completed electronically in the EHDI database.

• Newborn Hearing Screening Reporting Form
• Diagnostic Reporting Form
• Early Headstart/Parents as Teachers Reporting Form

Hearing Loss Checklist

This form should be used to assist families with next steps when their child has been diagnosed with hearing loss. This is only meant to be a guide.

• Hearing Loss Checklist

Parent Refusal Forms

These forms should be used if a parent wishes to decline hearing screening for their child. These forms should only be signed following education about newborn hearing screening.

• Hospital Form
• Birth Center/Midwife Form
• Other Provider Form

This form should be used if a parent wishes to decline diagnostic hearing assessment for their child. This form should only be signed following education about diagnostic hearing assessments.

• Diagnostic Refusal Form

This form should be used if a parent wishes to decline Congenital Cytomegalovirus (cCMV) testing. This form should only be signed following education about cCMV testing. For more information about cCMV testing, please visit The Center for Congenital and Inherited Disorders website at https://idph.iowa.gov/genetics.

• cCMV Refusal Form