Baby's Name (Last, First) or Imprint:	New Jersey Department of Health

Early Hearing Detection and Intervention Program

PO Box 364

Trenton, NJ 08625-0364

LOST TO HEARING FOLLOW-UP REPORT
Also Known As

Date of Birth

Sex

Male

Female	Medical Record Number

Name of Parent/Guardian (Last, First)

Name of Baby’s Physician

Relationship to Child

Physician Telephone Number

Physician Fax Number

Street Address

Physician Street Address

City	State	Zip Code

City	State	Zip Code

Parent/Guardian Telephone Number

Facility of Birth

Reason Testing was Required

Not Screened Previously	Return for Ear-Specific Results

Refer Result on Previous Screen ( OAE ABR Both): Right Ear Left Ear Both

Hospital Readmission in 1st Month for:

Hyperbilirubinemia w/exchange transfusion Culture positive sepsis
Other hospitalization (reason):
Risk Indicator 24-30 month follow-up (see instructions for codes):
Other:
Date Declared Lost To or Discharged From Follow Up:
LOST TO FOLLOW UP
Lost to Follow Up (check all that apply):
No show for scheduled visit, scheduled for [date(s)]:
Reminder letter to parent sent on [date(s)]:
Regular mail	Certified Mail
Returned undeliverable	No response
Phone contact with parent attempted on [date(s)]:
No answer	Left message	Phone number disconnected	Wrong Number
Notification sent to primary care provider on [date(s)]:
Family known to have moved out of state after delivery. New state of residence (if known):
Child in foster care; contact information unknown.
Other contact attempted (describe):
Discharge from NEW JERSEY Follow Up REQUIREMENTS
Discharged from Continued Follow Up (check all that apply):

Family declines follow-up testing (it is recommended that a written refusal signed by the parent/guardian be obtained for families refusing further testing). Indicate reason (lack of insurance coverage, does not feel additional testing is necessary, etc.):
Family resides out of state and will not receive follow-up care in New Jersey. Family should be provided with written documentation of need for follow-up testing.
Family resides in New Jersey, but is receiving continued follow-up care out of state. Family should be provided with written documentation of need for follow-up testing.
Location of follow-up testing:
Child expired. Date of death (if known):
Risk factor previously noted for this child was documented in error (ex: previously noted to have family history of hereditary childhood onset hearing loss, but hearing loss subsequently determined to be adult onset or due to infection, trauma, etc).
Explain:
Risk factor noted for this child is determined to be non-contributory for this infant (ex: family history of childhood onset hearing loss determined to be due to syndrome - CHARGE syndrome, Down syndrome, etc. - and that syndrome has been ruled out for this child).
Explain:
Name and Title of Person Completing Form

Telephone Number

Facility Name and Address

Instructions for Completing the

Lost to Hearing Follow-Up Report (SCH-3)

The Lost to Hearing Follow-up Report (SCH-3) submission is mandated by New Jersey rules (N.J.A.C. 8:19-1.10(c)) to notify the NJ Early Hearing Detection and Intervention Program of children that will not receive follow-up screening, audiologic evaluation or monitoring. Additional copies are for distribution to the child’s medical home and the birth facility’s maternity unit, and for the notifier’s medical record. Complete the Report for outpatient visits for children (age 0-3) who were expected to receive outpatient follow-up (not screened in hospital; did not pass initial screening; were referred for diagnostic audiologic evaluation; or were referred for audiologic monitoring for late onset hearing loss) that are noted to be lost to follow-up for any if the indications listed on the Report.

Multiple identifiers (names, DOB, facility of birth, etc.) are needed to match babies’ outpatient results to their inpatient screening status. Complete all fields as thoroughly as possible. If the reason for testing is not included in the check boxes or risk codes listed, please indicate the reason in the “Other” field.

Risk Indicator Codes: The NJ Early Hearing Detection and Intervention Program adheres to the most recent JCIH Position Statement regarding risk indicators and time frames requiring ongoing monitoring for late onset hearing loss. The current JCIH Statement (2007) includes the risk indicators below for at least one diagnostic evaluation by 24-30 months of age. Forms do not need to be submitted to indicate unsuccessful follow-up contacts for risk indicator-related contacts made before 24-30 months of age. Codes identified with an asterisk (*) are of greater concern for delayed-onset hearing loss and may require more frequent monitoring. Enter the appropriate code(s), including all codes that apply:

CO =	Caregiver concern* regarding hearing, speech, language and/or developmental delay

HX =	Family history* of permanent childhood hearing loss

NI =	Neonatal intensive care unit (NICU) admission of more than 5 days

EC =	Use of extracorporeal membrane oxygenation (ECMO)* during a NICU admission of >5 days

AV =	Use of assisted ventilation during a NICU admission of >5 days

OT =	Exposure to ototoxic medications (gentamycin and tobramycin) or loop diuretics (furosemide/Lasix) during a NICU admission of >5 days

HB =	Hyperbilirubinemia that requires exchange transfusion

TO =	In utero infections such as CMV (cytomegalovirus)*, herpes, rubella, syphilis and toxoplasmosis (TORCH)

CR =	Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear pits, and temporal bone anomalies

PF =	Physical findings, such as a white forelock, that are associated with a syndrome known to include a sensorineural or permanent conductive hearing loss

SY =	Syndromes associated with hearing loss or progressive or late-onset hearing loss* such as neurofibromatosis, osteopetrosis and Usher’s syndrome; other frequently identified syndromes include Waardenburg, Alport, Pendred, and Jervell and Lange-Nielson

ND =	Neurodegenerative disorders*, such as Hunter syndrome or sensory motor neuropathies such as Friedreich’s ataxia and Charcot-Marie-Tooth syndrome, etc.

PI =	Culture-positive postnatal infections associated with sensorineural hearing loss*, including confirmed bacterial and viral (especially herpes virus and varicella) meningitis

TR =	Head trauma, especially basal skull/temporal bone fracture* that requires hospitalization

CH =	Chemotherapy*

Date Declared Lost To or Discharged From Follow-Up: Enter the date here that the facility has determined that the child is to be classified as lost to follow-up. This may be the date of a missed appointment, the date a letter is returned undeliverable, the date a phone call was made revealing a disconnected line, the date at which a reconciliation has shown that the child has not returned for follow-up despite outreach efforts, etc.

Lost to Follow Up: This section should be used to indicate any unsuccessful efforts (letters, phone calls, etc.) made to contact the family to ensure follow up services for children that are still noted as needing these services. This will be the mechanism for documenting a birthing facility’s attempts to ensure that the family received services, as required by N.J.A.C. 8:19-1.9(h). Completion of the report is only necessary when those efforts have not resulted in follow-up services being obtained and documented via the Newborn Hearing Follow-Up Report (SCH-2).

Discharge from Continued Follow Up: This section should be used to indicate cases where continued audiologic follow-up in New Jersey is no longer mandated.

To request additional forms, call 609-292-5676 or download copies at: http://www.nj.gov/health/forms/sch-3.dot.

SCH-3 JUL 12	Distribution: Original-NJDOH Copy-Examiner Copy-Pediatrician Copy-Birth Hospital

SCH-3, Lost to Hearing Follow Up Report

SCH-3, hearing screening, special child health services, newborn hearing screening, SCH, hearing loss, newborn

EWhite

2005-09-29

NJDOH