State Forms

• State Form 57125: Indiana Newborn Screening Program Condition Nomination (Burmese, Haitian Creole, Spanish)
  • For Public and Healthcare Staff Use: This form is to be utilized to nominate a condition to be added to Indiana's newborn screening panel. Learn more about the condition nomination and evaluation process here!

State Form 54102: Religious Waiver for Newborn Screening (Burmese, Haitian Creole, Spanish)

• For Healthcare Staff Use Only: This form must be filled out and signed by the parent and hospital staff/midwife in every instance of a refusal of newborn screening. Every religious refusal must be entered as a Monthly Summary Report (MSR) exception within INSTEP by every birthing facility/midwife. Scan the completed Religious Waiver and upload it into the MSR exception in INSTEP. If the birthing facility/midwife is unable to electronically upload the Religious Waiver, they may fax or securely email it to the DBS & CCHD Screening Coordinator at 317-234-2995 or NewbornScreening@health.in.gov.

• INSTEP Access Request Form
  • For Healthcare Staff Use Only: This form should be utilized by healthcare providers and support staff to gain access to newborn screening results through the online INSTEP application.
• State Form 55649: Public Health Genetics Newborn Screening Access Request (Burmese, Haitian Creole, Spanish)
  • For Public and Healthcare Staff Use: This form should be filled out by parents who are requesting newborn screening results or dried blood spot specimens without the assistance of a healthcare provider. Parents are required to submit identification along with this request form. If you are a parent needing to request results, ask your child's healthcare provider to request the results for you. We are able to fax the results to the provider within 1-2 business days. If you do not have access to a healthcare provider, you may submit this form for a legal review. Once approved, we will mail the results through USPS. This process may take up to 2 weeks. Parents can learn more about requesting newborn screening results here.
  • Providers should use this form when requesting dried blood spot specimens.

• NBS Lab Change of Information Form
  • For Healthcare Staff Use Only: This form is to be utilized by birthing facility staff, midwife or physician to update or correct information that was previously submitted to the NBD lab.
• Storage and Use of Newborn Screening Dried Blood Spots (Spanish Version)
  • For Public Use: This form should be provided to families and completed by the parents/guardians prior to each newborn heel stick. The form allows the parent to indicate their preference for the storage of their infant's residual dried blood specimen. Every NBS card comes with its own unique consent form that must be completed and signed. Spanish-speaking families may utilize the "Spanish Version" of this form.
• State Form 55650: Request for Destruction of Dried Blood Spot (Burmese, Haitian Creole, Spanish)
  • For Public Use: This form should be filled out by parents who wish to have their child's dried blood spot specimen destroyed. If parents consent to storage, the specimen will be destroyed 3 years after time of collection. This form is intended to be used by parents within this 3-year timeframe who previously consented to storage of the dried blood spot, but change their mind and wish to have the specimen destroyed within the 3 years. Please note, all specimens will be kept for a minimum of 6 months after time of collection to allow for additional screening, if necessary.
• State Form 55651: Request for Storage of Dried Blood Spot (Burmese, Haitian Creole, Spanish)
  • For Public Use: This form should be filled out by parents who wish to have their child's dried blood spot specimen stored for 3 years. If the parents previously did not consent for storage of the dried blood spot, this form must be completed within 6 months after the heel stick was performed.
• State Form 57002: Release of Specimens for Research
  • For Healthcare or Research Staff Only: This form should be filled out by researchers or similar personnel when requesting physical dried blood spot specimens for use in research. This form must be completely filled out and submitted to the Genomics and Newborn Screening Program at NewbornScreening@health.in.gov, or by fax at 317-234-2995.