Form Cdc - Viral Hepatitis Case Report Page 4
ADVERTISEMENT
1
2
3
4
5
6DRAFT COPY
Perinatal Hepatitis B Virus Infection
NETSS ID NO.
STATE CASE NO. _________________________________________
RACE OF MOTHER:
ETHNICITY OF MOTHER:
Amer Ind or Alaska Native
Black or African American
White
Unknown
Hispanic ....................
Asian
Native Hawaiian or Pacific Islander
Other Race, specify: ______________
Non-hispanic .............
Other/Unknown .........
Yes
No
Unk
Was Mother born outside of United States? .................................................................
If yes, what country?___________________
Was the Mother confirmed HBsAg positive prior to or at time of delivery ? ...
•
If no, was the mother confirmed HBsAg positive after delivery? ....................
M M / D D / Y Y Y Y
Date of HBsAg positive test result ....................................................................................
How many doses of hepatitis B vaccine did the child receive ? ..................................
0
1
2
3
•
When?
•
M M / D D / Y Y Y Y
Dose 1-
•
M M / D D / Y Y Y Y
Dose 2-
•
M M / D D / Y Y Y Y
Dose 3-
Yes
No
Unk
Did the child receive hepatitis B immune globulin (HBIG)? .......................................
•
M M / D D / Y Y Y Y
If yes, on what date did the child receive HBIG? .................................................
5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal