Newborn screening guidelines in North Carolina recommend that the newborn screening test be obtained by filter paper sample prior to discharge(including hospital transfers) regardless of age or within the first 72 hours. Current policy recommends rescreening by 7 days of age if the sample was collected at <24 hours of age. North Carolina screens for the following: phenylketonuria, galactosemia, congenital adrenal hyperplasia, congenital hypothyroidism and sickle cell anemia. We have identified 369 infants transferred from an outside hospital for any reason to a tertiary care hospital (North Carolina Children's Hospital) within the first 21 days of life. The infants were identified retrospectively from all consecutive admissions over a two year period (July 1, 1994 to June 30, 1996). Our goal was to determine the rate of screening prior to transfer and to identify factors that influenced delay and possibly missed opportunities for screening. Medical record review has been completed for 93% of patients. Most of the infants were transferred because of critical illness. For more than 90% of the infants transferred to the neonatal intensive care unit (NICU) within the first 72 hours of age, there was no documentation that a sample was collected by the transferring hospital. Infants were more likely to have been screened prior to transport to the NICU if they were older than 72 hours (>80% tested). Delayed or missed screening most often occurred when an infant was transferred multiple times or admitted to other pediatric services. Some factors that contributed to missed screens included early infant death and severe congenital heart disease with some requiring early surgery. Verification of medical record newborn screening data by comparison with state laboratory data is now in progress.