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Congenital Heart Disease Screening
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Congenital Heart Disease Screening Program Data reporting

Name of Institution*
Number of infants passed*
Number of infants failed*
If failed, condition(s) found
Period recorded
(Eg: 01/01/2010 - 03/01/2010)*
Average age at screening (Hrs)*
Barriers faced while screening*
Additional comments
Form completed by
(First & last name, Credentials)*
Phone Number:*
Email Address*

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