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Newborn Screening Ontario
Hearing Loss Risk Factor Screening

Forms

Risk Factor Screening for Permanent Hearing Loss - Requisition for Additional Interpretation and Testing

  • This form is to be used for result or test requests for babies who have confirmed PHL, suspected or confirmed CMV, or a personal/family history of genetic risk factors.
  • If risk factor screening was not performed for a child (e.g. they were born before July 29, 2019 or a parent/guardian did not consent), testing of the residual dried blood spot sample for CMV using PCR for viral DNA can be requested using this form for children 19 years of age or under.
  • For children with Permanent Hearing Loss and negative risk factor screening results, NSO can provide additional interpretation and testing.  This involves reporting whether or not a mutation was identified on the screening panel. If one mutation was identified, a health care provider may choose to seuqnce the relevant gene before considering extended gene panel testing.
  • Please call 613-738-3222 with any questions.