Free INDIANA STATE DEPARTMENT OF HEALTH - Indiana

REQUEST FOR ADMINISTRATIVE FORMS AND INFORMATION MATERIALS
State Form 53274 (5-07)

Reset Form

Early Hearing Detection & Intervention Universal Newborn Hearing Screening

Date __________________
(month/day/year)

Name of Hospital/Birthing Facility ___________________________________________ Address _______________________________________________________________
(Number & Street)

______________________________________________________________________
(City, State, & Zip Code)

Name of Contact Person _____________________________________ Phone Number _____________________________________________ E-mail Address _____________________________________________

Please send the requested items listed below to the address indicated above.
Items

# of Copies

The Who, What, and Why of the Program (English) The Who, What, and Why of the Program (Spanish) Hearing Screening Certificate(English) Hearing Screening Certificate (Spanish) What If Your Baby Needs More Hearing Tests? (English) What If Your Baby Needs More Hearing Tests? (Spanish) Indiana Family Resource Guide for Children with Hearing Loss Hospital Policy Manual Monthly Summary Report Form First Steps Referral Form Delta Zeta & NCHAM Sound Beginnings Video on DVD (English - 3 copies max.) Delta Zeta & NCHAM Sound Beginnings Video on DVD (Spanish - 3 copies max.)

If you need assistance, please call 317-233-1254 or 888-815-0006. or Mail or fax your request to: Indiana State Department of Health Newborn Screening Programs Early Hearing Detection & Intervention Program 2 North Meridian Street, 7F Indianapolis, IN 46204 Fax: 317-234-2995 ________________________________________________________________________ ISDH Office Use Order received ____________________ Order filled ____________________