Newborn Screening Materials and Resources:
Education Materials and Forms

Newborn screening fact sheetThe Minnesota Newborn Screening Program provides many education materials and forms for parents and providers free of charge. Orderable materials can be requested through the online ordering form or by printing the Education Materials Ordering Form and faxing or mailing it to the Newborn Screening Program. Before placing your order, please reference the list of materials and forms below to determine whether the form you wish to order is printable or orderable.

List of Printable Education Materials and Forms
List of Orderable Education Materials and Forms

To place an order using the online form:
Online Order Form for Education Materials and Forms

To place an order using the printable form:
Print Order Form for Education Materials and Forms (PDF: 169KB/1 page)

Please contact the Newborn Screening Program at 651-201-5466 or 800- 664-7772 with any questions about available materials or how to place an order.


Printable Education Materials and Forms

Legal Forms for Parents

Directive to Destroy Newborn Screening Blood Spots and Test Results and/or Hearing Screening Test Results (PDF: 125KB/1 page)
Parents who wish to request the destruction of their child's newborn screening blood spots and blood spot test results and/or hearing screening results must complete and sign this form. This form applies to any hearing screening test results on file at MDH and to blood samples collected on or after August 1, 2014 and the test results obtained from them.

Parental Consent for MDH to Store and Use Newborn Screening Blood Spots and Test Results (PDF: 82KB/3 pages)
Parents who would like to authorize the extended storage and use of their child's blood spots and test results collected before August 1, 2014 must complete and sign this form.

Parental Consent for Research Use of Newborn Screening Blood Spots and Test Results (PDF: 86KB/3 pages)
Parents who would like to authorize the use of their child's blood spots and test results collected on or after August 1, 2014 for public health studies or research must complete and sign this form.

Parental Refusal of Newborn Screening (PDF: 121KB/1 page)
Parents who choose to refuse newborn screening must complete and sign this form. A copy will be sent to the Newborn Screening Program.

Parental Revocation of Written Consent for Storage and Research Use of Newborn Screening Blood Spots and Test Results (PDF: 92KB/1 page)
Parents who would like to revoke consent for storage and use of newborn screening blood spots and test results must complete and sign this form.

Education Materials for Parents

Newborn Hearing Screening for Out-of-Hospital Births Handout (PDF: 85KB/2 pages)
This handout is a printer-friendly version of the tri-fold brochure that is available to order above. The handout gives an overview of the importance of hearing screening, how screening works, and what results mean.

Materials and Forms for Providers

Audiology Report for the Newborn Screening Program (PDF: 455KB/1 page)
This form is designed for audiologists to report screening results and hearing diagnoses to the Newborn Screening Program.

Hearing Report for the Newborn Screening Program (PDF: 694KB/1 page)
All hearing evaluations performed after the initial newborn hearing screening should be reported to the Newborn Screening Program using this form.

Newborn Screening: Pre-Transfer Checklist (PDF: 135KB/1 page)
This laminated flyer/poster is designed to remind birth providers of newborn screening protocol during the busy time prior to a transfer. Please contact the newborn screening program if you would like to order laminated copies for your facility.

Purchase/Replacement Request form (PDF: 127KB/1 page)
Hospitals, providers, and parents can order newborn screening cards by mailing this completed form to the Newborn Screening Program along with a check payable to “Treasurer, State of Minnesota.”


Orderable Education Materials and Forms

Newborn Screening

Newborn Screening Fact Sheet (PDF: 242 KB/2 pages)
This fact sheet is designed for providers to give to new parents following delivery to help guide a discussion about newborn screening. Every parent should receive a copy of the fact sheet prior to having their newborn screened.
*Available in Hmong, Karen, Russian, Somali, and Spanish*

Newborn Screening for Parents-to-be (prenatal handout) (PDF: 215KB/2 pages)
This half-sheet is designed for prenatal care providers to give to expecting parents during a discussion about newborn screening. MDH recommends that providers share this half-sheet with all expecting parents at least once during the third trimester of pregnancy, but invites providers to share this information with families throughout the prenatal period.
*Available in Hmong, Karen, Russian, Somali, and Spanish*

Newborn Screening for Prenatal Providers (provider folder) (PDF: 393KB/2 pages)
This folder is designed to give prenatal care providers all the information they need for introductory discussions with expecting parents about newborn screening. The folder contains a built-in pocket designed to hold Prenatal Education Brochures for providers to give to expecting parents.

Hearing Screening

Newborn Hearing Screening Fact Sheet (PDF: 319KB/2 pages)
This supplemental fact sheet is designed for providers to give to expecting and new parents to help guide a discussion about newborn hearing screening. Providers may want to have these sheets available for families who have further questions about newborn hearing screening.

PASS Result: Hearing Screening Result Notification (PDF: 470KB/2 pages)
This information sheet is designed for providers to give to families of infants who receive a PASS result in both ears on the newborn hearing screen. Providers should fill in the blanks with the infant's information and give the form to the parents for their reference. This form may also be used by the screening provider to notify the infant's primary care provider of the hearing screen results.
*Available in Hmong, Karen, Russian, Somali, and Spanish*

REFER Result: Hearing Screening Result Notification (PDF: 317KB/2 pages)
This information sheet is designed for providers to give to families of infants who receive a REFER result in one or both ears on the newborn hearing screen. Providers should fill in the blanks with the infant's information and give the form to parents to bring to their infant's primary care provider. This form may also be used by the screening provider to notify the infant's primary care provider of the hearing screen results.
*Available in Hmong, Karen, Russian, Somali, and Spanish*

Newborn Hearing Screening Transfer Form (PDF: 205KB/1 page)
This form is designed to help birth facilities/units alert receiving facilities/units that an infant is being transferred before a hearing screen was performed. MDH recommends that all birth facilities/units have a supply of forms available to send with transfer teams for all infants who have not yet had their hearing screened.

Newborn Hearing Screening Out-of-Hospital Birth Brochure
This supplemental tri-fold brochure is designed for out-of-hospital birth providers to give to expecting and new parents to help guide a discussion about newborn hearing screening. The brochure gives an overview of the importance of hearing screening, how screening works, and what results mean.

Notification of Newborn Hearing Screening Appointment (PDF: 76KB/1 page)
This form is designed for out-of-hospital birth providers who are referring an infant to another provider for newborn hearing screening. MDH recommends that providers fill out the form with the infant's information and the screening appointment details, make a copy of the form for the infant's family, and mail or fax the completed form to MDH within 10 days of the infant's birth.

My Child's Hearing Checklist
This supplemental handout is designed for providers to give to families of infants who receive a PASS result in both ears on the newborn hearing screen. This handout outlines what language milestones parents can expect throughout their child's first two years of life.
*Available in Hmong, Somali, and Spanish*

Pulse Oximetry Screening

Did Not Pass Result: Pulse Oximetry Result Notification (PDF: 160KB/1 page)
This result notification sheet is designed for providers to give to families of newborns with a not passing result immediately following pulse oximetry screening. In addition to explaining the newborn’s result, the handout outlines what parents can expect to happen next and provides additional resources for the family.
*Available in Hmong, Karen, Russian, Somali, and Spanish*

Pass Result: Pulse Oximetry Result Notification (PDF: 224KB/1 page)
This result notification sheet is designed for providers to give to families of newborns with a passing result immediately following pulse oximetry screening. In addition to explaining the newborn’s result, the handout also outlines what signs parents should be aware of after they take their newborn home that could indicate a possible CCHD not detected by screening.
*Available in Hmong, Karen, Russian, Somali, and Spanish*

Pulse Oximetry Screening Protocol for CCHD and Tips for Screeners (PDF: 217KB/2 pages)
This laminated, double-sided handout is designed to provide a quick reference for screeners when performing pulse oximetry screening. The handout contains a flowchart depicting the recommended pulse oximetry screening protocol in Minnesota, as well as tips for providers on where to place the sensors and how to best communicate screening results with the family.

DOs & DON’Ts of Pulse Oximetry Screening (PDF: 104KB/1 page)
This laminated handout provides a quick reference of best practices for pulse oximetry screening. The Newborn Screening Program recommends that nurseries keep a copy of this handout with each set of screening equipment for screeners to reference at all times.