Hearing Screener Contract Newborn Hearing Screening Equipment Responsibility Agreement First name Last name I hereby request privileges to use the newborn hearing screening unit, in order to screen infants for hearing loss, within the parameters of the State of Wisconsin hearing screening program http://www.slh.wisc.edu/clinical/newborn/health-care-professionals-guide/hearing-screening/. Host Name I recognize that the MAICO EroScan and Otodynamics hearing screeners are the property of the Wisconsin Guild of Midwives, and the screener is being issued to the screening host for the sole purpose of providing newborn hearing screening in accordance with the provisions of Wisconsin Act 279. I agree to use this equipment consistent with the use for which it is intended. I agree to pay $10.00 for each baby that I screen, to the Wisconsin Guild of Midwives on a YEARLY schedule. I will mail a check or pay by Zeffy online. If mailing a check, please indicate payment specifically assigned to the hearing screening program. WGOM Treasurer: Jade Dillman 715-491-3224 5420 20th Ave Eau Claire, WI 54703 Jmdillman1552@gmail.com Zeffy Online Payment: https://wisconsinguildofmidwives.org/hearing-screen-payments/ An annual assessment to determine unpaid fees will be conducted by the Board of Directors. I understand that if no payments are received by December 31st each year, my privileges of using the screener may be revoked. Payments received support the sustainability of our hearing screening program. The funds will be allocated for the cost of annual calibration, repair and replacements as needed. I agree to use this equipment consistent with the use for which it is intended. I agree to work cooperatively with other midwives in my region to ensure that all midwives have access to hearing screening equipment within a timely manner. I agree to report to DHS, in the form and manner prescribed by the Department, the aggregate results of screenings performed by using WE-TRAC or the out of hospital data reporting procedure within 30 days of birth. I agree to assist in transporting the hearing screener to a designated location for annual calibration. I agree not to leave the machine in an insecure location or in extreme temperatures, to clean it appropriately, and to read the user manual before use of the machine. I understand that I am liable for serious damages or loss of the equipment while the equipment is in my possession. If the equipment malfunctions, or if I suspect a malfunction, I will promptly contact the President of the Wisconsin Guild of Midwives. I agree to notify the WGOM upon the event that the hearing screening device will no longer be in my possession as the primary host for the device. If the hearing screener is being under-utilized or used improperly, I understand that it can be removed from my possession. The WGOM will re-disperse the screener to a location of higher volume/need. I understand that signing this Responsibility Agreement is a prerequisite to using this newborn hearing screening equipment. I understand that in order to use this equipment, I and any other midwives who intend to use the hearing screening equipment must be current members of the Wisconsin Guild of Midwives and must have been trained in the use of the equipment and follow-up and reporting requirements. I agree to the terms, conditions, and obligations stated above in this Responsibility Agreement. This document will be updated and signed each year upon recalibration of the machine. A copy of this record will be housed with a designated board member of the WGOM. Please complete the details requested below. For further support and information please contact Tamara Thompson cell: (608)-332-4861. Or the President of the WGOM – Miranda Welch presidentwgom@protonmail.com Newborn Hearing Screening Equipment Responsibility Agreement First and Last Name Date Phone Number Address Wisconsin License Number Hearing Screener Equipment Serial Number Electronic Signature Other practitioners assigned to use this equipment: Full Name Phone Number Wisconsin License Number Full Name Phone Number Wisconsin License Number Full Name Phone Number Wisconsin License Number Full Name Phone Number Wisconsin License Number
