c) Medical care facilities shall submit the following for every newborn, infant or child to whom a newborn hearing screening test is administered:

1. 1) Newborn, infant or child's name (first, middle and last);
2. 2) Newborn, infant or child's date of birth;
3. 3) Nursery, i.e., NICU, SCBU, well baby;
4. 4) Newborn, infant or child's gender;
5. 5) Newborn, infant or child's birth order;
6. 6) Newborn, infant or child's place of birth;
7. 7) Unique identification number assigned to newborn, infant or child's;
8. 8) Full legal name of both parents;
9. 9) Full legal name of legal guardian or caregiver, if applicable;
10. 10) Date of birth of both parents;
11. 11) Date of birth of legal guardian or caregiver, if applicable;
12. 12) Time, date, screening technology and individual-ear screening results for each screening session;
13. 13) Any risk factors for hearing loss;
14. 14) Follow-up plan of care;
15. 15) Medical care facility to where the newborn, infant or child is transferred, date of transfer and reason for transfer, if applicable;
16. 16) Date of death for newborns, infant or children who expire prior to discharge, if applicable;
17. 17) Name of the facility or physician submitting the test results; and
18. 18) Address of facility or physician submitting the test results.

d) Medical care facilities shall submit the following for every newborn, infant or child who does not pass the final hearing screening prior to discharge:

1. 1) Residential address and telephone number, including street address, city, county, state and ZIP code of newborn or infant;
2. 2) Residential address and telephone number, including street address, city, county, state and ZIP code of both parents, legal guardian or caregiver, if different from residential address and telephone number of the newborn, infant or child;
3. 3) Interventions administered, if any;
4. 4) Support services referrals, if any; and
5. 5) Name and address of primary healthcare provider who will care for the newborn, infant or child after discharge.

e) EHDI service providers

1. 1) EHDI service providers shall submit the following information:

   1. A) Provider, location and type of hearing testing; ear specific information; diagnosis; treatment plan; and recommendations;
   2. B) Broken or re-scheduled appointments;
   3. C) Follow-up services;
   4. D) Part C and non-Part C intervention services, supports and enrollment status for the newborn, infant or child and the newborn, infant or child's family, legal guardian or caregiver; and
   5. E) Parent, parent-to-parent or EHDI-related support services.

2. 2) Service provider submissions shall include, at a minimum, the following:

   1. A) Newborn, infant or child's name (first, middle and last);
   2. B) Newborn, infant or child's date of birth;
   3. C) Newborn, infant or child's gender;
   4. D) Newborn, infant or child's primary healthcare provider or clinic;
   5. E) Newborn, infant or child's birthplace, if available;
   6. F) Residential address and telephone number, including street address, city, county, state and ZIP code of newborn, infant or child;
   7. G) Residential address and telephone number, including street address, city, county, state and ZIP code of both parents, legal guardian or caregiver, if different from residential address and telephone number of newborn, infant or child;
   8. H) Primary language spoken in the home of the newborn, infant or child, if available;
   9. I) Name, address and credentials of service provider; and
   10. J) Any known risk factors for hearing loss, if available.

f) The Department of Human Services, Bureau of Early Intervention or their designee shall submit the following minimum information:

1. 1) Enrollment status of any newborn, infant or child with a confirmed or suspected hearing loss;
2. 2) Dates of service to include at minimum referral, enrollment, and exit dates for early intervention services;
3. 3) Early intervention service coordinator, early intervention audiologist, and early intervention services listed on the individualized family service plan (IFSP); and
4. 4) Reason for record closure when applicable.