Required fields are marked with asterisks (*)

Risk Factor Screening Results Request Form

Please fill out this form if you would like to request a baby’s risk factor screening results for permanent hearing loss (CMV and genetic risk factors).

For the privacy and protection of this child, this form must be completed by the child's parent, guardian, or health care provider. Results will be released to the health care provider you list below.

If you are a health care provider and you would like to request additional testing for a child with confirmed or suspected cCMV or permanent hearing loss, please contact us. Alternatively, you could visit our Requisitions page for the appropriate requisition.

Who is completing this form?

I am this child's parent and legal guardian

I am this child's legal guardian (please download the request form above and mail it to NSO with the completed Proof of Guardianship form)

I am this child's health care provider

Your name:

Your phone number