Att 3a - Data Elements

Att3a DataElements.doc

Congenital Syphilis Case Investigation and Report Form

Att 3a - Data Elements

OMB: 0920-0128

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Congenital Syphilis (CS) Case Investigation and Report Form


0920-0128


Attachment 3a


Information content of proposed nationally notifiable congenital syphilis case report by data element








Form Approved:

OMB No. 0920-0128

Exp. Date: 00/00/0000


Public reporting burden of this collection of information is estimated to average 20 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0128)





Congenital Syphilis (CS) Case Investigation and Report Form


The CS form is a carbonless three-copy form.



Table 1. Proposed data to be collected on the CS Case Investigation and Report Form by health agencies for submission to CDC:


Part I – Maternal Information (abstracted from medical record)


1. Report date to health department

2. Reporting state

3. Reporting county

4. Mother’s state FIPS code and state of residence

5. Mother’s Country of residence

6. Mother’s county FIPS code and County of residence

7. Mother’s residence zip code

8. Mother’s date of birth

9. Mother’s obstetric history

10. Mother’s Last menstrual period (before delivery)

11. Date of first prenatal visit

12. Mother’s ethnicity

13. Mother’s race (other is an option, as data is

abstracted from the medical record.)

14. Did mother have a non-treponemal or treponemol test at first prenatal visit, 22-28 weeks of gestation or delivery?

15. Mother’s marital status

16. Dates and results of non-treponemal tests

17. Dates types and results of treponemal tests during

pregnancy

18. Mother’s HIV status during pregnancy

19. Mother’s clinical stage of syphilis during

pregnancy

20. Mother’s surveillance stage of syphilis during

pregnancy

21. When did the mother receive her first dose of

Benzathine penicillin?

22. What was mother’s treatment?

23. Did mother have an appropriate serologic response?


Part II – Infant/Child Information (abstracted from medical record)


24. Date of Delivery

25. Vital status

26. Date of death

27. Birth weight

28. Estimated gestational age

29. a) Did infant/child have a reactive non-

treponemal test for syphilis?

b) When was infant/child’s first reactive non-

treponemal test for syphilis?

c) Indicate titer of infant/child’s first reactive

non-treponemal test for syphilis.

30. a) Did infant/child have a reactive treponemal

test for syphilis?

b) When was infant/child’s first reactive

treponemal test for syphilis?

31. Did infant/child, placenta, or cord have a

darkfield exam,DFA or special strains?

32. Did infant/child have any signs of CS?

33. Did infant/child have long bone X-rays?

34. Did infant/child have a CSF-VDRL?

35. Did infant/child have a CSF WBC count or CSF

protein test?

36. Was infant/child treated?


Part III – Congenital Syphilis Case Classification


37. Classification



Table 2. Data elements collected on the CS Case Investigation and Report Form by health agencies, but NOT transmitted to CDC:


Mother’s Name

Mother’s Chart Number

Mother’s Case ID Number

Mother’s Address

Mother’s Phone Number

Infant’s Name

Infant’s Chart Number

Delivering Physician

Physician’s Phone Number

Pediatrician

Pediatrician’s Phone Number

Delivering Hospital

OB/GYN


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Authorgks7
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File Modified2012-12-05
File Created2012-11-28

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