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pdfOMB Control No. 0920-0978
Expiration Date: 02/28/2019
Infant’s Name: _______________________________________________________________________________
Infant’s Chart No.: ________________________________________________
Mother’s Name: _______________________________________________________________________________
Mother’s Chart No.: ______________________________________________
Mother’s Date of Birth: __ __ /__ __ /__ __ __ __
Mother’s Prenatal Care Provider: ______________________________________________
Clinic Name: ______________________________________________
(Last, First, M.I.)
(Last, First, M.I.)
month day year (4 digits)
Culture date: ________________________
Infant
Mother
Clinic Phone Number: ______________________________________________
Hospital Name: ______________________________ Estimated Due Date: : __ __ /__ __ /__ __ __ __
- Patient identifier information is
NOT transmitted to CDC -
2015 ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form
Indicate type of HiNSES case:
Neonatal (infant) - complete Q1-9b, then skip to maternal section (Q12-31)
Pregnant or post-partum (if pregnant or post-partum, specify outcome of pregnancy):
Spontaneous Abortion- complete Q1-2b, then skip to maternal section (Q12-30)
Live Birth - complete Q1-11, then skip to maternal section (Q12-30)
Stillbirth - complete Q1-3, then skip to maternal section (Q12-30)
Infant Information
W ere labor & delivery records available?
Induced Abortion (end form)
Yes (1)
No (0)
1. Date of live birth/stillbirth/spontaneous abortion: __ __ /__ __ /__ __ __ __ Time : ___ ___ ___ ___
month
day
(times in military format)
year (4 digits)
2. Gestational age of infant live birth/stillbirth/spontaneous abortion in completed weeks: __ __
2a. Determined by:
Dates
Physical Exam
2b. Date of maternal last menstrual period (LMP): __ __ /__ __ /__ __ __ __
3. Birth weight: ___ lbs ___oz OR __ __ __ __ grams
day
year (4 digits)
Unknown (1)
4. Date & time of newborn discharge from hospital of birth: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
5. Was the infant transferred to another hospital following birth?
Yes (1)
if YES, Hospital where infant was transferred __ __ __ __ __ ID
AND date of transfer __ __ /__ __ /__ __ __ __ month / day / year (4 digits)
AND date of discharge __ __ /__ __ /__ __ __ __ month / day / year (4 digits)
6. Was the infant discharged to home and readmitted to the birth hospital?
IF YES, date & time of readmission: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
AND date of discharge __ __ /__ __ /__ __ __ __
day
year (4 digits)
AND date of discharge __ __ /__ __ /__ __ __ __
__ __ __ __
No (0)
time
Unknown (9)
Yes (1)
No (0)
__ __ __ __
time
Unknown (1)
Unknown (9)
month / day / year (4 digits)
7. Was the infant admitted to a different hospital from home?
AND date & time of admission: __ __ /__ __ /__ __ __ __
month
(do not round up)
Unknown
Ultrasound
month
Unknown (1)
Yes (1)
No (0) IF YES, hospital ID: __ __ __ __ __
__ __ __ __
Unknown (1)
time
month / day / year (4 digits)
8. Outcome of infant :
Unknown (9)
Survived (1) Died (2)
8a. If survived, did the infant have the following neurologic or medical sequelae evident on discharge (check all that apply)
None
Requiring oxygen
Seizure disorder
Hearing impairment
9. Was the infant admitted to the NICU during hospitalization?
Yes (1)
No (0)
Unknown (9)
9a. If infant was discharged home and readmitted, was infant admitted to NICU during rehospitalization?
Yes (1)
No (0)
Unknown (9)
9b. If yes, to either 9 or 9a, total number of days in the NICU. __ __ __
*Questions 10-11: Only for live births of pregnant and post-partum HiNSES cases
10. From time of birth to date of discharge, did the infant have a
temperature ≥ 100.4 F/38 C?
Yes (1)
No (0)
Unknown (9)
10a. If yes, were any bacterial cultures performed from time of birth to date of discharge? __ Yes _No
10b. If cultures performed from time of birth to date of discharge, list the culture date(s), source(s), and result(s).
Results
Culture Date
Culture Source
#1. __ __ / __ __ / __ __ __ __
__ Blood __ CSF __ Other (specify)
#2. __ __ / __ __ / __ __ __ __ __ Blood _ CSF __ Other (specify)
Positive (specify organism) _____________
Negative
Result unknown
Positive (specify organism) _____________
Negative
Result unknown
Public 10/2015
reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
Page 1instructions,
of 4
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 information, including suggestions for reducing this burden to CDC, CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30329, ATTN: PRA(0920-0978)
10c. If any sterile site culture positive for Hi, list ABCs State ID assigned to infant case.
__ __ __ __ __ __ __
*For live births of pregnant and postpartum HiNSES cases only:
11. Were any ICD-9 codes reported in the discharge diagnosis of the infant’s chart?
Yes (1)
No (0)
Unknown (9)
11a. IF YES, Were any of the following ICD-9 codes reported in the discharge diagnosis of the chart? (Check all that apply)
771.81: Septicemia of newborn
320.0: Haemophilus meningitis
995.91: Sepsis
762.7: Chorioamnionitis affecting fetus or newborn
038.41 Septicemia due to H. influenzae
670.22 Puerperal sepsis, delivered with mention of postpartum
482.2: Pneumonia due to H. influenzae
complication
11b. Were any ICD-10 codes reported in the discharge diagnosis of the infant’s chart?
Yes (1)
No (0)
Unknown (9)
11c. IF YES, were any of the following ICD-10 codes reported in the discharge diagnosis of the chart? (Check all that apply)
A41.3: Sepsis due to H. influenzae
J14: Pneumonia due to H. influenzae
G00.0: Haemophilus meningitis
P36.8: Other bacterial sepsis of newborn
P36.9: Bacterial sepsis of newborn, unspecified
P02.7: Chorioamnionitis
O85: Puerperal sepsis
O75.3: Sepsis during labor
Maternal Information
12. Maternal admission date & time: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
__ __ __ __
Unknown (1)
time
13. Maternal age at delivery (years): __ __ years
14. Number of prior pregnancies __ __
15. Any prior history of preterm births? (< 37 weeks gestation al age)
16. Did mother receive prenatal care?
Yes (1)
Yes (1)
No (0)
No (0)
Unknown (9)
Unknown (9)
17. Please record the following: the total number of prenatal visits AND the first and last visit dates to the prenatal
as recorded in the labor and delivery chart
No. of visits: __ __ First visit: __ __ /__ __ /__ __ __ __ Last visit: __ __ /__ __ /__ __ __ __
Unknown (1)
month
day
year (4 digits)
month
day
year (4 digits)
18. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
19. Did mother have a prior history of penicillin allergy?
IF YES, was a previous maternal history of anaphylaxis noted?
20. Date & time of membrane rupture: __ __ /__ __ /__ __ __ __
month
21. Was duration of membrane rupture
day
≥ 18 hours?
year (4 digits)
Yes (1)
Yes (1)
No (0)
Yes (1)
No (0)
__ __ __ __
22. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?
Yes (1)
23. Type of rupture:
Unknown (9)
Spontaneous (1)
Artificial (2)
Unknown (1)
time
No (0)
Unknown (9)
No (0)
23a. If artificial rupture, reason for rupture (check all that apply)
Gestational diabetes
Fetal distress
Severe fetal growth restriction
Suspected chorioamnionitis
Post-term pregnancy
Preclampsia/eclampsia/hypertension
Other, specify ___________________
Maternal bleeding
10/2015
Page 2 of 4
Unknown (1)
Unknown (9)
Unknown
24. Type of delivery: (Check all that apply)
Vaginal (1)
Forceps (1)
If delivery was
by C-section:
Vaginal after previous C-section (1)
Primary C-section (1)
Vacuum (1)
Did labor begin before C-section?
Repeat C-section (1)
Unknown (1)
Yes (1)
No (0)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
Did membrane rupture happen before C-section?
24a. If delivery by primary C-section was it scheduled or emergency?
Emergency
Scheduled
24b. If emergency primary C-section. What was the reason? (check all that apply)
Placenta previa/abruption
Uterine rupture
Breech position
Cord prolapse
25. Intrapartum fever (T ≥ 100.4 F or 38.0 C):
IF YES, 1 recorded T
st
Eclampsia//preclampsia/hypertension
Diabetes
Maternal infection
Fetal distress
Failure to progress
Yes (1)
No (0)
Unknown (9)
≥ 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month
day
Unknown
Other (specify)
_____________
year (4 digits)
__ __ __ __
Unknown (1)
time
25a. If intrapartum fever present, were any bacterial cultures performed during labor? __ Yes __ No
25b. If cultures performed during labor, list the culture date(s) during labor, source(s), and result(s)?
Culture Date
Culture Source
Results
__ Blood __ Vaginal __ Urine __ Cervical
__ Placental __ Amniotic Fluid __ Other
(specify)
Positive (specify organism) _____________
Negative
Result unknown
#2. __ __ / __ __ / __ __ __ __ __ Blood __ Vaginal __ Urine __ Cervical
__ Placental __ Amniotic Fluid __ Other
(specify)
Positive (specify organism) _____________
Negative
Result unknown
#1. __ __ / __ __ / __ __ __ __
25c. If any sterile site cultures were positive for H. Influenzae, list ABCs State ID assigned to
maternal case. __ __ __ __ __ __ __
26.
Were antibiotics given to the mother intrapartum?
Yes (1)
No (0)
Unknown (9)
IF YES, answer a-b and Questions 27-28
a) Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __
month
b) Antibiotic 1: ___________________________
Start date: __ __ /__ __ /__ __ __ __
10/2015
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: ___________________________
Start date: __ __ /__ __ /__ __ __ __
Unknown (9)
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 5: ___________________________
Start date: __ __ /__ __ /__ __ __ __
time
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 4: ___________________________
Start date: __ __ /__ __ /__ __ __ __
__ __ __ __
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 3: ___________________________
Start date: __ __ /__ __ /__ __ __ __
IM (2)
year (4 digits)
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Antibiotic 2: ___________________________
Start date: __ __ /__ __ /__ __ __ __
IV (1)
day
IV (1)
IM (2)
PO (3) # doses given before delivery: ______
Stop date (if applicable): __ __ /__ __ /__ __ __ __
Page 3 of 4
27.
Interval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)
___ ___ (minutes) ___ ___ (days)*
*Day variable should only be completed if the number of hours >24
28.
What was the reason for administration of intrapartum antibiotics? (Check all that apply)
GBS prophylaxis (1)
Suspected amnionitis/
chorioamnionitis (1)
Prolonged latency (1)
C-section prophylaxis (1)
Mitral valve prolapse prophylaxis (1)
Other (1)
Unknown (1)
Yes (1)
29. Did mother have chorioamnionitis or suspected chorioamnionitis?
No (0)
30. During the intrapartum period did the mother have any of the following symptoms or diagnoses? (check all that apply)
Uterine tenderness
Maternal tachycardia (>100 beats/min)
Maternal WBC >20 or 20,000
Foul smelling amniotic fluid
Fetal tachycardia (>160 beats/min)
Urinary tract infection
Questions 31-32d apply only to mothers of HiNSES infant cases
31.
Post-partum fever (temperature ≥ 100.4 F/38 C)?
Yes (1)
No (0)
Unknown (9)
31a. If yes, were any bacterial cultures performed post-partum? __ Yes __ No
31b. If cultures performed post-partum, list the culture date(s), source(s) and result(s).
Results
Culture Date
Culture Source
__ Blood __ Vaginal __ Urine __ Cervical
__ Placental __ Amniotic Fluid __ Other
(specify)
Positive (specify organism) _____________
Negative
Result unknown
#2. __ __ / __ __ / __ __ __ __ __ Blood __ Vaginal __ Urine __ Cervical
__ Placental __ Amniotic Fluid __ Other
(specify)
Positive (specify organism) _____________
Negative
Result unknown
#1. __ __ / __ __ / __ __ __ __
31c: If any sterile site cultures were positive for H. influenzae,list ABCs State ID assigned to
maternal case. __ __ __ __ __ __ __
31d: Were any of the following ICD-9 or ICD-10 codes reported in the discharge diagnoses of the mother’s chart?
ICD-9
ICD-10
995.91: Sepsis
A41.3: Sepsis due to H. influenzae
J14: Pneumonia due to H. influenzae
038.41 Septicemia due to H. influenzae
482.2: Pneumonia due to H. influenzae
G00.0: Haemophilus meningitis
320.0: Haemophilus meningitis
P02.7: Chorioamnionitis
O85: Puerperal sepsis
762.7: Chorioamnionitis affecting fetus or newborn
O75.3: Sepsis during labor
670.22: Puerperal sepsis, delivered, with mention of postpartum complication
670.20: Puerperal sepsis, unspecified as to episode of care or not applicable
670.24: Puerperal sepsis, postpartum condition or complication
32. COMMENTS: ______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
33.
HiNSES Form Tracking Status
Complete (1)
10/2015
Partial (2)
Chart unavailable (3)
Page 4 of 4
Edited & corrected (4)
| File Type | application/pdf |
| File Title | HiNSES CRF.pdf |
| File Modified | 2016-03-01 |
| File Created | 2012-11-15 |