Provider Forms and Materials

Blood Spot Screening Forms & Requests

This brochure is available for hospitals, clinics, and midwives to provide to their patients.

This form is used for patients who would like their child's blood spot card returned to them after processing.

This form is for medical providers to request access to obtain test results.

To view a copy of the ND blood spot card, click here. 

Order newborn screening supplies and forms.

Hearing Screening & Diagnostic Reporting Forms

Access the online case management system OZ eSP to find results for patients. 

To request an OZ eSP user account, contact Christine at 701-858-3580 or christine.brigden@ndus.edu or 
Jerusha at jerusha.olthoff@ndus.edu 

For any password or access issues contact the helpdesk at 866-427-5768. 

CCHD Reporting & Forms

To ensure data accuracy, the pediatric cardiologist or a designated member of the cardiology team, should complete the reporting form within three months of the baby's first cardiology visit. A nurse from the Newborn Screening Program will contact the parent/guardian of a child with CCHD on a routine basis after their child is diagnosed to ensure the family has the needed resources and services, they need to keep their child healthy.

1. Copy of the CCHD Reporting Form

2. Online CCHD reporting form

3. List of Reportable Conditions

Miscellaneous Forms

The Car Seat Sticker helps alert Emergency Medical Services (EMS) personnel that a child may have a medical condition, disability, or medical device requiring special consideration during emergency care.

The sticker is designed to be placed on a child's car seat or booster seat and serves as a visual alert for first responders when a parent or caregiver may be unable to communicate important medical information.

Healthcare providers are encouraged to offer stickers to families of children with:

  • Complex or chronic medical conditions
  • Medical technology dependence
  • Developmental or physical disabilities
  • Conditions that may impact emergency assessment or treatment

Providers may request stickers for distribution to eligible families in the link below.

https://ndhealth.co1.qualtrics.com/jfe/form/SV_9uZezZSdHpquyJo