Newborn Screening Materials and Resources:
Education Materials and Forms

Parental Refusal or Delay of Newborn Screening (PDF) form

Directive to Destroy Newborn Blood Spots and/or Newborn Screening Test Results (PDF) form

A Complete Blood Spot Screen: 24-hour Specimen + Post-transfusion Specimen (PDF)
This pdf illustrates which disorders on the newborn screening panel are valid when collected less than 24-hours or post-transfusion.

Newborn Screening Audiology Follow-up Report Form
This form is designed for audiologists to report screening results and hearing diagnoses to our program.

Hearing Screening and Pulse Oximetry Results Report Form (PDF)

Hearing Report for the Newborn Screening Program (PDF)
All hearing evaluations performed after the initial newborn hearing screening should be reported to our program using this form.

Newborn Screening Fact Sheet (PDF)
This fact sheet is designed for providers to give new parents following delivery to help guide a discussion about newborn screening. Every parent should receive a copy of the Newborn Screening Fact Sheet AND Newborn Screening Infographic prior to screening.
*Available in Hmong, Karen, Russian, Somali, and Spanish* see below

Newborn Screening Fact Sheet - Hmong (PDF)

Newborn Screening Fact Sheet - Karen (PDF)

Newborn Screening Fact Sheet - Russian (PDF)

Newborn Screening Fact Sheet - Somali (PDF)

Newborn Screening Fact Sheet - Spanish (PDF)

Newborn Screening Amish Brochure
This simple brochure is designed for midwives and public health nurses to give Amish parents to help guide a discussion about newborn screening. The brochure prints in black and white and includes sketched artwork.

Newborn Screening Infographic (PDF)
This infographic is designed to help providers educate parents about newborn screening and their options after screening. Every parent should receive a copy of the Newborn Screening Fact Sheet AND Newborn Screening Infographic prior to screening.
*Available in Hmong, Karen, Russian, Somali, and Spanish* see below

Newborn Screening Infographic - Hmong (PDF)

Newborn Screening Infographic - Karen (PDF)

Newborn Screening Infographic - Russian (PDF)

Newborn Screening Infographic - Somali (PDF)

Newborn Screening Infographic - Spanish (PDF)

Newborn Screening for Parents-to-be (PRENATAL HANDOUT) (PDF)
This half-sheet is designed for prenatal care providers to give to expectant parents during a discussion about newborn screening. We recommend that providers share this half-sheet with all expectant 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 (FOLDER) (PDF)
This folder is designed to give prenatal care providers all the information they need for introductory discussions with expectant parents about newborn screening. The folder contains a built-in pocket designed to hold Newborn Screening for Parents-to-be handouts for providers to give to expectant parents.

Newborn Screening for Prenatal Providers (POCKET CARD) (PDF)
This two-sided pocket card (3.75 x 6.75 in) is designed as a quick reference for prenatal providers while discussing newborn screening with expectant parents. The back side includes frequently asked questions and answers.

Listen to MinneStories™ (PDF)
This material is for families who are going through the process of diagnosis and beginning the journey of seeking out support and resources.

Share Your MinneStory™ postcard (PDF)
This material is for families who are further along in their journey and in a position to share their own MinneStory with others to help cultivate community for others.

Newborn Hearing Screening Fact Sheet (PDF)
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 Screen Result Notification (PDF)
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* see below

PASS Result: Hearing Screen Result Notification - Hmong (PDF)
PASS Result: Hearing Screen Result Notification - Karen (PDF)
PASS Result: Hearing Screen Result Notification - Russian (PDF)
PASS Result: Hearing Screen Result Notification - Somali (PDF)
PASS Result: Hearing Screen Result Notification - Spanish (PDF)

REFER Result: Hearing Screen Result Notification (PDF)
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* see below

Refer Result: Hearing Screen Result Notification - Hmong (PDF)
Refer Result: Hearing Screen Result Notification - Karen (PDF)
Refer Result: Hearing Screen Result Notification - Russian (PDF)
Refer Result: Hearing Screen Result Notification - Somali (PDF)
Refer Result: Hearing Screen Result Notification - Spanish (PDF)

Newborn Hearing Screening for Out-of-Hospital Births (PDF) 
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)
This form is designed for out-of-hospital birth providers who are referring an infant to another provider for newborn hearing screening. We recommend 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 our program within 10 days of the infant's birth.

Did Not Pass Result: Pulse Oximetry Screen Result Notification (PDF)

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* see below

Did Not Pass Result: Pulse Oximetry Screen Result Notification - Hmong (PDF)
Did Not Pass Result: Pulse Oximetry Screen Result Notification - Karen (PDF)
Did Not Pass Result: Pulse Oximetry Screen Result Notification - Russian (PDF)
Did Not Pass Result: Pulse Oximetry Screen Result Notification - Somali (PDF)
Did Not Pass Result: Pulse Oximetry Screen Result Notification - Spanish (PDF)

Pass Result: Pulse Oximetry Screen Result Notification (PDF)
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 critical congenital heart disease (CCHD) not detected by screening.
*Available in Hmong, Karen, Russian, Somali, and Spanish* see below

Pass Result: Pulse Oximetry Screen Result Notification - Hmong (PDF)
Pass Result: Pulse Oximetry Screen Result Notification - Karen (PDF)
Pass Result: Pulse Oximetry Screen Result Notification - Russian (PDF)
Pass Result: Pulse Oximetry Screen Result Notification - Somali (PDF)
Pass Result: Pulse Oximetry Screen Result Notification - Spanish (PDF)
 

Pulse Oximetry Screening Protocol and Tips for Screeners (PDF)
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)
This laminated handout provides a quick reference of best practices for pulse oximetry screening. We recommend that nurseries keep a copy of this handout with each set of screening equipment for screeners to reference at all times.