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pdfNEONATAL GROUP B STREPTOCOCCAL DISEASE PREVENTION TRACKING FORM
Infant’s Name: _____________________________________________
Infant’s Chart No.: _____________________
Mother’s Name: _____________________________________________
(Last, First, M.I.)
Hospital Name: _____________________________________________
Mother’s Chart No.: ____________________
(Last, First, M.I.)
Culture date: _________________________
*Patient identifier information is NOT transmitted to CDC *
ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs)
NEONATAL GROUP B STREPTOCOCCAL DISEASE PREVENTION TRACKING FORM
STATEID __ __ __ __ __ __ __
HOSPITAL ID (of birth; if home birth leave blank) __ __ __ __ __
Infant Information
Were labor & delivery records available?
month
day
2. Did this birth occur outside of the hospital?
Yes (1)
No (0)
Unknown (9)
IF YES, please check one:
Home Birth (1)
Unknown (1)
En route to hospital (3)
Other (4)
year (4 digits)
Time of birth: ___ ___ ___ ___
(times in military format)
month
Survived (1)
Died (2)
7. Readmitted to the same hospital:
day
year (4 digits)
Unknown (1)
time
Unknown (9)
Yes (1)
No (0)
IF YES, date & time of readmission: __ __ /__ __ /__ __ __ __
month
8. Admitted from home to different hospital:
Birthing Center (2)
Unknown (9)
4. Birthweight: ___ lbs ___oz OR __ __ __ __ grams
(do not round up)
5. Date & time of newborn discharge after birth: __ __ /__ __ /__ __ __ __ __ __ __ __
6. Outcome:
No (0)
1. Date of Birth: __ __ /__ __ /__ __ __ __
3. Gestational age in completed weeks: __ __
Yes (1)
day
__ __ __ __
year (4 digits)
Yes (1)
time
No (0)
IF YES, hospital id: ___ ___ ___ ___ ___ AND date & time admission: __ __ /__ __ /__ __ __ __
month
OMB No. 0920-0802
9. Infant discharge diagnosis:
ICD9-1 __ __ __.__ __
ICD9-2 __ __ __.__ __
day
__ __ __ __
year (4 digits)
time
ICD9-3 __ __ __.__ __
10. Did the baby receive breast milk from the mother? (for late-onset cases only)
IF YES, did the baby receive breast milk before onset of GBS
infection (eg, date of first positive neonatal culture):
Yes (1)
No (0)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
Maternal Information
11. Maternal admission date & time: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
Maternal age at delivery (years): __ __ years
__ __ __ __
Maternal blood type:
12. Did mother have a prior history of penicillin allergy?
IF YES, was a previous maternal history of anaphylaxis noted?
13. Date & time membrane rupture: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
Unknown (1)
time
A (1)
B (2)
Yes (1)
No (0)
Yes (1)
No (0)
__ __ __ __
time
AB (3)
O (4)
Unknown (1)
14. Was duration of membrane rupture >18 hours?
Yes (1)
No (0)
Unknown (9)
15. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?
Yes (1)
No (0)
Unknown (9)
16. Type of rupture:
Spontaneous (1)
Artificial (2)
Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data /needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
currently valid OMB /control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, CDC/ATSDR
Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0802). Do not send the completed form to this address.
1/2008
Page 1 of 3
Maternal Information (continued)
17. Type of delivery: (Check all that apply)
Vaginal (1)
Vaginal after previous C-section (1)
Primary C-section (1)
Forceps (1)
Vacuum (1)
Unknown (1)
Repeat C-section (1)
If delivery was by C-section: Did labor or contractions begin before C-section?
Yes (1)
No (0)
Unknown (9)
Did membrane rupture happen before C-section?
Yes (1)
No (0)
Unknown (9)
18. Intrapartum fever (T > 100.4 F or 38.0 C):
Yes (1)
No (0)
Unknown (9)
IF YES, 1st recorded T > 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month
day
__ __ __ __
year (4 digits)
time
19. Did mother receive prenatal care?
Yes (1)
No (0)
Unknown (9)
20. Was prenatal record (even partial information) in labor and delivery chart?
Yes (1)
No (0)
Unknown (9)
IF YES: No. of visits: __ __ First visit: __ __ /__ __ /__ __ __ __ Last visit: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
month
day
year (4 digits)
21. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
22. GBS
bacteriuria during this pregnancy?
Yes (1)
No (0)
IF YES, what order of magnitude was the colony count?
0 (1)
<10,000 (2)
10k–<25,000 (3)
25k–<50,000 (4)
50k–<75,000 (5)
>100,0000 (7)
Unknown (9)
23. Previous infant with invasive GBS disease?
Yes (1)
No (0)
24. Previous pregnancy with GBS colonization?
Yes (1)
No (0)
75k–<100,000 (6)
25a. Was maternal group B strep colonization screened for BEFORE admission (in prenatal care)?
Yes (1)
No (0)
Unknown (9)
IF YES, list dates, test type, and test results below:
Test date (list most recent first):
1. __ __ /__ __ /__ __ __ __
2. __ __ /__ __ /__ __ __ __
Test type:
Culture (1)
Rapid pcr (2)
Other (4)
Unknown (9)
Culture (1)
Rapid pcr (2)
Other (4)
Unknown (9)
Positive culture
(Do not include urine here!)
Rapid antigen (3)
Yes (1)
No (0)
Unknown (9)
Rapid antigen (3)
Yes (1)
No (0)
Unknown (9)
25b. If the most recent test was GBS positive, was antimicrobial susceptibility performed?
Yes (1)
IF YES, Was the isolate resistant to clindamycin?
Yes (1)
No (0)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
Was the isolate resistant to erythromycin?
26a. Was maternal group B strep colonization screened for AFTER admission (before delivery)?
Yes (1)
No (0)
Unknown (9)
No (0)
Unknown (9)
IF YES, list date of most recent test, test type and test results below:
Test date (list most recent first):
__ __ /__ __ /__ __ __ __
Test type:
Culture (1)
Rapid pcr (2)
Other (4)
Unknown (9)
Page 2 of 3
Rapid antigen (3)
Positive culture
(Do not include urine here!)
Yes (1)
No (0)
Unknown (9)
Maternal Information (continued)
26b. If the most recent test was GBS positive, was antimicrobial susceptibility performed?
IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?
27.
Yes (1)
No (0)
Yes (1)
No (0)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
Were GBS test results available to care givers at the time of delivery?
Yes (1)
No (0)
Unknown (9)
Unknown (9)
Intrapartum Antibiotics
28.
Were antibiotics given to the mother intrapartum?
IF YES, answer a-b and Question 29-30
a) Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __
Yes (1)
No (0)
month
b) Antibiotic 1: ___________________________
Start date: __ __ /__ __ /__ __ __ __
Start date: __ __ /__ __ /__ __ __ __
Start date: __ __ /__ __ /__ __ __ __
Start date: __ __ /__ __ /__ __ __ __
Start date: __ __ /__ __ /__ __ __ __
Start date: __ __ /__ __ /__ __ __ __
PO (3) # doses given before delivery: ______
IV (1)
IM (2)
PO (3) # doses given before delivery: ______
IV (1)
IM (2)
PO (3) # doses given before delivery: ______
IV (1)
IM (2)
PO (3) # doses given before delivery: ______
IV (1)
IM (2)
PO (3) # doses given before delivery: ______
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 6: ___________________________
time
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 5: ___________________________
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 4: ___________________________
year (4 digits)
__ __ __ __
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 3: ___________________________
IM (2)
day
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 2: ___________________________
IV (1)
Unknown (9)
IV (1)
IM (2)
PO (3) # doses given before delivery: ______
Stop date (if applicable): __ __ /__ __ /__ __ __ __
29. Interval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)
___ ___ (minutes)
30. What was the reason for administration of intrapartum antibiotics? (Check all that apply)
GBS prophylaxis (1)
C-section prophylaxis (1)
Mitral valve prolapse prophylaxis (1)
Suspected amnionitis (1)
Other (1)
Unknown (1)
Comments: ___________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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| File Type | application/pdf |
| File Modified | 2009-02-05 |
| File Created | 2009-02-05 |