Please fill out this form if you are concerned about your child's stool colour according to the instructions on the Infant Stool Colour Card (ISCC). NSO will contact you within the next business day via the contact information you provide. If you have concerns about your baby other than stool colour, please contact your healthcare provider. Notices: By using this form, you consent to the collection and use of your information by Newborn Screening Ontario as described in the policy for Collection of Biliary Atresia (BA) Screening Information. Your privacy and personal health information is protected. Click here to view Newborn Screening Ontario's Privacy and Confidentiality Policy. If at any time you wish to withdraw your consent, contact NSO. Child's Demographics First Name * Last Name * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023 Sex * Female Male Health Card Number (OHIP) * 10-digit health card number. Do not enter the last two letters (version code). If child does not have health card, enter "NA" Contact Demographics Full Name * Phone Number * Email Address * Relationship to Child * - Select -ParentLegal GuardianHealth Care ProviderFamily Member Preferred Contact Time * - Select -No PreferenceMorningAfternoon Preferred Contact Language * - Select -EnglishFrenchArabicBengaliCreeChineseDariEastern OjibweFarsiGermanGreekGujaratiHindiInuktitutItalianKoreanMandarin (Simplified Chinese)OjiCreePashtoPolishPortugesePunjabiRomanianRussianSerbianSomaliSpanishTagalogTamilTigrinyaUkrainianUrduVietnamese Stool Information Stool Colour * Based on the images on your infant stool colour card, please select the colour(s) that are most like your child's poop. You may select more than one choice. 1 2 3 4 5 6 7 8 9 Stool Pictures If possible, please upload up to two pictures of your child's stool. This is not required but will be helpful for our team to assess whether your child may screen positive for biliary atresia. Best Practices: Ensure the photo focuses on the stool: You do not need to capture the surrounding area of the diaper/change-table. Do not include the face of your child, body parts, or any other person in the picture. Take pictures in a well-lit room/environment: Unless necessary, avoid using the flash on your phone or camera. The flash may distort the stool colour in the image. Do not markup or edit the picture in any way. Stool Photo Upload 1 If possible, please upload up to two pictures of your child's stool. This is not required but will be helpful for our team to assess whether your child may have Biliary Atresia. Stool Photo Upload 2 Files must be less than 2 MB.Allowed file types: gif jpg jpeg png. Consent * I consent to submitting the above information to Newborn Screening Ontario for the purposes of helping to screen my child for Biliary Atresia in accordance with Newborn Screening Ontario's privacy policy and policy on collection of biliary atresia screening information. Newborn Screening Ontario will not use this information for any purpose not identified. I understand that I may withdraw consent at any time by contacting Newborn Screening Ontario. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image. Français
