NEWBORN HEARING SCREENING SURVEY
Note: This is not an electronic
survey form. Please print the form and fill it out offline.
Please send completed survey to:
SECTION I. Demographic Information
(to be completed by all hospitals)
1. Hospital/Birthing Center:___________________________________
Contact Person:______________________________________________
Title of Contact Person_________________________________________
Address: ___________________________________________________
City __________________State _____________Zip_________________
Phone Number, including area code: (___)____________extension_______
Fax Number, including area code: (____)_____________
Email Address:_____________________________________________
2. Do you birth babies at your hospital?
__ Yes
__ No
3. What was your birthing census in 1997?
______ babies were born in our facility in 1997.
4. What is the geographic location of your hospital?
__ Rural (community served has population less than 100,000)
__ Urban (community served has population more than 100,000)
__ Frontier (community served has population < 6
people/square mile)
__ Military base
__ Other, please describe____________________________________
5. What types of nurseries are available in your hospital/center?
__ Level I (well-baby care)
__ Level II (Neonatal Intensive Care Unit, NICU)
__ Level III (NICU)
6. What is the average length of stay for infants who were delivered vaginally?
(Check one)
__ 12 hours
__ 24 hours
__ 48 hours
__ Other, please
describe_________________________________________
7. Please complete the following table regarding the methods of payment used by
patients in your health care facility.
| Method of Payment |
Check here if your center receives this
type of payment. |
If you checked box to left, estimate
percentage of total patient population who uses this type of payment. |
| Medicaid |
|
_____________ % |
| Managed Care (HMO, EPO, PPO) |
|
_____________ % |
| Indemnity Plan |
|
_____________ % |
| Private Pay (No insurance) |
|
_____________ % |
| Other, please describe___________ |
|
_____________ % |
8. Does your hospital have an audiologist on staff?
__ Yes
__ No
9. Does your hospital have a newborn hearing screening program?
__ Yes. Please continue to Section II, question #11.
__ No. Please complete question #10.
10. If your hospital does not currently have a newborn hearing screening program,
are you interested in starting a newborn hearing screening program?
__ Yes (If your hospital does not currently have a screening program,
do not continue on to section II. Send survey to address listed on page 1. )
__ No
Section II. Birthing Centers with Newborn Hearing Screening
Programs
11. Manager of the Newborn Hearing Screening Program
__ Same as contact person listed in question #1, page 1.
Name of Manager:___________________________________________
Title of Manager_____________________________________________
Address:___________________________________________________
City__________________State_____________Zip__________________
Phone Number, including area code: (___)__________extension_______
Fax Number, including area code: (___)__________
Email Address:_____________________________________________
12. Audiologist on staff of hospital and/or affiliated with Newborn Hearing Screening
Program
__ No audiologist is on staff or affiliated with our
program.
__ Same as person listed in question #1, page 1.
__ Same as manager of newborn hearing screening program.
Name of Audiologist:___________________________________________
Title of Audiologist_____________________________________________
Address:___________________________________________________
City__________________State_____________Zip__________________
Phone Number, including area code: (___)__________extension_______
Fax Number, including area code: (___)__________
Email Address:_____________________________________________
Please note the abbreviations used in the remainder of this survey:
OAE; Otoacoutic Emissions
TEOAE: Transient Evoked Otoacoustic Emissions
DPOAE: Distortion Product Otoacoustic Emissions
AABR: Automated Auditory Brainstem Response
ABR: Auditory Brainstem Response
13. What methods of newborn hearing screening does your hospital/center use before
discharge? Check all that apply.
__ Screening deferred to outpatient setting.
__ High Risk Register using a questionnaire on all infants before
discharge
__ High Risk Register using a questionnaire on NICU infants
only before discharge
__ Screen all infants before discharge using
physiological test (ABR, AABR, and/or OAE)
__ Screen only infants with high risk factors before
discharge with physiological test (ABR, AABR, and/or OAE).
__ Screen NICU infants only with physiologic test (ABR, AABR,
and/or OAE) before discharge
__ Noisestik, noisemakers and/or warblet on all infants before
discharge
__ Noisestik, noisemakers and/or warblet on NICU only before
discharge
__ Noisestik, noisemakers and/or warblet on HRR only before discharge
14. If you screen using a physiologic-based technology, which procedure(s) do you
use on all babies you screen? Check all that apply.
__ OAEs Indicate type(s) of OAEs used: __ TEOAE __ DPOAE
__ AABR
__ ABR
__ Other, please
specify__________________________________________
15. What personnel does your hospital use for screening? Check all that apply.
__ Nurses
__ Technicians
__ Volunteers
__ Audiologists
__ Other, please specify ____________________________________
16. How is consent for screening obtained from parents? Check all that apply.
__ Consent is implied as part of routine neonatal
admission
__ Written information provided for parent but no specific
consent is obtained.
__ Verbal information is provided for parent but no specific
consent is obtained.
__ Verbal permission is obtained.
__ Written permission is obtained.
17. Check all of the following that apply to your screening program:
__ Screening is a standing order from all physicians
__ Screening is not a uniform standing order: some physicians
order screening for some babies
18. How are parents informed about a "pass" result from the screening?
Please check all that apply.
__ Screening personnel inform parents.
__ Physician informs parents.
__ Audiologist informs parents.
__ Parents are informed by mail.
__ Parents are informed by phone call.
__ Parents are informed verbally before hospital discharge.
__ Parents are informed through written material before
hospital discharge.
__ Parents are not informed of a test "pass" result.
19. How are parents informed about a referral? Please check all that apply.
__ Screening personnel inform parents.
__ Physician informs parents.
__ Audiologist informs parents.
__ Parents are informed by mail.
__ Parents are informed by phone call.
__ Parents are informed verbally before hospital discharge.
__ Parents are informed through written material before
hospital discharge.
__ Parents are not informed about a referral.
20. When an infant refers from the screen, do you recommend the baby return for an
outpatient re-screen?
__ Yes. Please complete questions 21 and 22.
__ No. Please go to question 23.
21. What technology do you use to re-screen? Check all that apply.
__ ABR
__ AABR
__ DPOAE
__ TEOAE
22. What personnel does your hospital use for outpatient re-screening? Please check all
that apply.
__ Nurses
__ Technicians
__ Volunteers
__ Audiologists
__ Other, please
describe_______________________________________
23. What type of hospital based data management system(s) do you use? Check all that
apply.
__ We use a manual data management system.
__ We use a computerized system developed for use by our site.
__ We use the Databook (Natus) computerized system.
__ We use the Hi Track (NCHAM) computerized system.
__ We use the Oz computerized system.
__ We use the Biologic computerized system.
__ Other, please
specify_________________________________________
24. To which of the following individuals/agencies do you report screening results?
Check all that apply.
__ Parents
__ Primary Care Physicians
__ State Health Department
__ State Department of Education
__ Part C
__ Early Intervention Services
__ Local "Child Find" Team
__ Other, please describe________________________________
25. Who refers the family for a diagnostic evaluation following the
"screening" process? Check all that apply.
__ Nursery Staff
__ Physician
__ Audiologist
__ Coordinator of Newborn Hearing Screening Program
__ Other, please describe_____________________________________
26. Who is responsible for assuring that an infant who is referred from screening
receives a diagnostic evaluation? Check all that apply.
__ Nursery Staff
__ Physician
__ Audiologist
__ Coordinator of Newborn Hearing Screening Program
__ Other, please describe_____________________________________
27. How do you identify/ monitor infants at risk for progressive hearing loss?
Please check all that apply.
__ We do not identify infants at risk for progressive
hearing loss.
__ High risk indicators established by the Joint Committee on
Infant Hearing
__ Provide parents with information regarding progressive
hearing loss
__ Refer for audiological monitoring
__ Other, please
describe__________________________________________
28. For babies referred from screening, what information do you provide families
regarding their options for obtaining diagnostic audiological services? Check all that
apply.
__ No specific information is given regarding diagnostic
audiological services.
__ Family is informed about audiologic services available
within our hospital.
__ Family is given a referral list consisting of all audiologists in the community.
__ Family is given a referral list consisting of a subset of
audiologists in the community.
__ Family is given information about Public Health/ State
supported audiology services. __ Other, please
describe_________________________________________
29. Who monitors the outcomes of diagnostic referrals? Please check all that apply.
__ Outcomes are not monitored at this time
__ Outcomes are monitored by a State Health Department
tracking system
__ Outcomes are monitored by a hospital-based system.
__ Outcomes are monitored by a community/regional tracking
system
__ Outcomes are monitored by an audiologist.
30. Please check all of the following that apply to outside funding used to support
your program.
__ We do not receive outside funding.
__ We receive outside funding from service organizations.
__ We receive outside funding from hospital auxiliaries.
__ We receive outside funding from Part C.
__ We receive outside funding from the State Health
Department.
__ Other:______________________________________________
31. If you have a universal newborn hearing screening program, what percentage of
infants are referred for further testing at the time they are discharged from the
hospital?
__ 1% or less
__ 2%
__ 3%
__ 4%
__ 5%
__ between 6% and 10%
__ between 11% and 15%
__ between 16% and 20%
__ greater than 20%
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