Congenital Syphilis Case Investigation and Report

Form Approved

OMB No. 0920-0128

Expiration Date: 00/00/0000

Congenital Syphilis (CS) Case Investigation and Report Form

0920-0128

Attachment 3c

Local Use Only

Mother's

Name:

_____________________________________________

Chart

No.:

_______________

Mother’s

Case ID No.: ­_______________

Address:

_______________________________________________________

___________

Phone

No.:

( )____________

(Number, Street, City, State) (Zip Code)

(Zip Code)

Infant's

Name:

___________________

Chart

No.:

______________

Delivering

Physician:

___________

Phone

No.:

( )____________

Pediatrician:

__________________

Phone

No.:

( )____________

Delivering

Hospital: _______________________

– Patient identifier information is not transmitted to CDC –

OB/Gyn: __________________ Other geographic unit: ____ ____ ____

CONGENITAL SYPHILIS (CS) CASE

INVESTIGATION AND REPORT

Form Approved OMB No. 0920-0128 Exp. Date: MM/YYYY

CASE ID No.:

(1-7)

____________

DEPARTMENT OF

HEALTH & HUMAN SERVICES

CENTERS FOR DISEASE CONTROL and PREVENTION

ATLANTA, GA 30333

Local Use ID No.:

___________

1. Report date to health dept. O9 Unk

__ __ / __ __ / __ __ __ __ Mo. Day Yr.

2. Reporting state FIPS code: 9 Unk

____ ____ ___________________________

Reporting State Name

3. Reporting county FIPS code: 9 Unk

____ ____ ____ _________________________

Reporting County Name

PART I. MATERNAL INFORMATION

4. Mother’s state FIPS code: 9 Unk

____ ____ ___________________________

Mother’s Residence State

5. Mother’s Country of residence: (leave blank if USA)

____ ____ ___________________________

Mother’s Country of Residence

6. Mother’s residence county FIPS code:

9 Unk

7. Mother’s residence

ZIP code; 9 Unk

___ ___ ___ ___ ___

8. Mother's date of birth: 9 Unk

9. Mother’s obstetric history: G_{—— ——} P_{—— —-—}

____ ____ ____ _________________________

Mother’s Residence County

__ __ / __ __ / __ __ __ __

Mo. Day Yr.

(G=pregnancies, P=live births)

10. Last menstrual period (LMP) (before delivery)

9 Unk

11. a) Indicate date of first prenatal visit:

0 No prenatal care (Go to Q12) 9 Unk

b) Indicate trimester of first prenatal visit:

__ __ / __ __ / __ __ __ __

1 1st trimester 2 2nd trimester 3 3rd trimester

Mo. Day Yr.

__ __ / __ __ / __ __ __ __

Mo. Day Yr.

12. Mother's ethnicity: 1 Hispanic or Latino

2 Non-Hispanic or Latino

9 Unk

13. Mother's race:

(check all that apply)

American

Indian/Alaska Native

Asian

Black or African American Native Hawaiian or Other Pacific

Islander

White

Other Unk

14. Did mother have non-treponemal or treponemal tests at:

15. Mother's marital status:

a) first prenatal visit?

b) 28–32 weeks gestation?

c) delivery?

1 Single, never married

3 Separated/Divorced

8 Other

1 Yes

2 No

9 Unk

1 Yes

2 No

9 Unk

1 Yes

2 No

9 Unk

2 Married

4 Widow

9 Unk

16. Indicate during pregnancy and delivery, dates and results of a) most recent and b) first non-treponemal tests:

19. What CLINICAL stage of syphilis did mother have during pregnancy?

Date

Mo. Day Yr.

Results

Titer

1 primary 3 early latent 5 previously 9 Unk

treated/serofast

a.__ __/__ __/__ __ __ __ 9 Unk

1 Reactive

2 Nonreactive

9 Unk

1:_ _ _ _

2 secondary 4 late or late latent 8 Other

b.__ __/__ __/__ __ __ __ 9 Unk

1 Reactive

2 Nonreactive

9 Unk

1:_ _ _ _

20. What SURVEILLANCE stage of syphilis did mother have during pregnancy? (Footnote a)

17. Indicate during pregnancy, date, type, and result of a) first and b) most recent treponemal tests:

1 primary 3 early latent 9 Unk

Date

Mo. Day Yr.

Test Type

Results

2 secondary 4 late or late latent 8 Other

a.__ __/__ __/__ __ __ __ 9 Unk

1 EIA or CLIA

2 TP-PA

3 Other

9 Unk

1 Reactive

2 Nonreactive

9 Unk

21. When did mother receive her first dose of benzathine penicillin?

__ __/__ __/__ __ __ __ Mo. Day Yr.

b.__ __/__ __/__ __ __ __ 9 Unk

1 EIA or CLIA

2 TP-PA

3 Other

9 Unk

1 Reactive

2 Nonreactive

9 Unk

1 Before pregnancy 3 2nd trimester 5 No Treatment (Go to Q24)

2 1st trimester 4 3rd trimester 9 Unk

18. What was mother’s HIV status during pregnancy?

P positive E equivocal test X patient not tested

22. What was mother's treatment?

N negative U Unk

1 2.4 M units benzathine

penicillin

3 7.2M units benzathine

penicillin

9 Unk

PART II. INFANT/CHILD INFORMATION

2 4.8 M units benzathine

penicillin

8 Other

24. Date of Delivery: 9 Unk

__ __/__ ___/__ __ __ __

Mo. Day Yr.

25. Vital status:

26. Indicate date of death 9 Unk

__ __/__ ____/__ __ __ __

Mo. Day Yr.

23. Did mother have an appropriate serologic response? (Footnote b)

1 Alive

(Go to Q27)

3 Stillborn (Go to Q27) (Footnote c)

1 Yes, appropriate response

3 Response could not be

determined from available

non-treponemal titer information

2 Born alive, then died

9 Unknown (Go to Q27)

2 No, inappropriate response: evidence of treatment failure or reinfection

4 Not enough time for titer to change

27. Birthweight

(in grams) 9 Unk

___ ___ ___ ___

28. Estimated gestational age

(in weeks) 99 Unk

____ ____

(If infant was stillborn go to Q37)

29. a) Did infant/ child have a reactive b) When was the infant/child’s first

non-treponemal test for syphilis? reactive non-treponemal test for

(eg., VDRL, RPR) Syphilis?

1 Yes 2 No 3 No test 9 Unk __ __/__ __/__ __ __ __

Mo. Day Yr.

(Go to Q30 unless reactive)

c) Indicate titer of infant/ child's non-treponemal test for syphilis

1: __ __ __ __

30. a) Did infant/child have a reactive treponemal test for syphilis (footnote d) 1 Yes 2 No 3 No test 9 Unk	b) When was the infant/child's first reactive treponemal test for syphilis? (footnote d)
	__ __/__ __/__ __ __ __ Mo. Day Yr.

31. Did the infant/child, placenta, or cord have darkfield exam, DFA, or

special stains?

1 Yes, positive

2 Yes, negative

3 No test

9 Unk

4 No lesions and no tissue to test

32. Did the Infant/child

have any signs of CS? (check all that apply)

no signs/ asymptomatic

(Footnote e)

condyloma

Lata

snuffles

syphilitic

skin rash

hepato splenomegaly

jaundice/

hepatitis

pseudo

paralysis

edema

other

Unk

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

1 Yes, changes consistent with CS 2 Yes, no signs of CS 3 No X-rays 9 Unk.

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

1 Yes, reactive

2 Yes, nonreactive 3 No test 9 Unk.

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

CSF protein test? (Footnote f)

1 Yes, CSF WBC

count elevated

2 Yes, CSF protein

elevated

3 both tests elevated

4 neither test elevated

5 No test

9 Unk

36. Was the infant/child

treated?

1 Yes, with Aqueous or Procaine

Penicillin for 10 days

(“2” is an obsolete response)

3 Yes, with Benzathine

penicillin x 1

4 Yes, with other treatment

5 No treatment

9 Unk

PART III. Congenital Syphilis Case Classification

37. Classification

1 Not a case

2 Confirmed case (Laboratory confirmed identification of T.pallidum,

e.g., darkfield exam, DFA, or special stains)

3 Syphilitic stillbirth

(Footnote c)

4 Probable case (A case identified by the algorithm, which is not a

confirmed case or syphilitic stillbirth).

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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0128). Do not send the completed form to this address.