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
| File Type | application/msword |
| Author | gks7 |
| Last Modified By | CDC User |
| File Modified | 2012-12-05 |
| File Created | 2012-11-28 |