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__________________________________________
(Last, First, M.I.)
Culture date: __ __ /__ __ /__ __ __ __
month / day / year (4 digits)
Infant’s Name: ________________________________________________ Estimated
(Last, First, M.I.)
__ /__ __ /__ __ __ __
Infant’s Chart No.:_____________________________________________ Due Date: __month
/ day / year (4 digits)
Infant
STATE ID:___ ___ ___ ___ ___ ___ ___
Mother
Mother’s Prenatal Care Provider: ____________________________________________
Clinic Name: _____________________________________________
Clinic Phone Number: _____________________________________________
Mother’s Name: ______________________________________________ Mother's
(Last, First, M.I.)
__ /__ __ /__ __ __ __ Hospital Name: ___________________________________________________
Mother’s Chart No.: ___________________________________________ Date of Birth: __
month / day / year (4 digits)
- Patient identifier information is
NOT transmitted to CDC -
2019 ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form
Indicate type of HiNSES case:
Maternal cases: pregnant or post-partum (sterile isolates only)
Live Birth (hospitalized) - complete #1-31
Stillbirth (hospitalized)- complete #1-3,12-31
Spontaneous Abortion - complete #1-2b,12-18, and 28-31
Home delivery (any outcome) - end form
Induced Abortion - end form
Pregnancy outcome unknown - end form
Neonatal: infant
(sterile isolates only)
- complete #1-31
Infant Information
Fetal Cases (any gestational age - specify isolate/outcome):
Hi from sterile site in stillbirth - complete #1-3, 12-31
Fetal death Hi isolated from placenta/amniotic fluid:
Stillbirth - complete #1-3,12-31
Spontaneous abortion - complete #1-2b,12-18, and 28-31
Were labor & delivery records available?
1. Date of live birth/stillbirth/spontaneous abortion: __ __ /__ __ /__ __ __ __ Time : ___ ___ ___ ___
month
day
year (4 digits)
Form Approved
0920-0978
No (0)
Yes (1)
Unknown (9)
(times in military format)
2. Gestational age of infant live birth/stillbirth/spontaneous abortion in completed weeks: __ __ (do not round up)
2a. Determined by:
Dates
Physical Exam
Unknown
Ultrasound
2b. Date of maternal last menstrual period (LMP): __ __ /__ __ /__ __ __ __
month / day / year (4 digits)
Unknown (9)
3. Birth weight: ___ lbs ___oz OR __ __ __ __ grams
4. Date & time of newborn discharge from hospital of birth: __ __ /__ __ /__ __ __ __
month
day
5. Was the infant transferred to another hospital following birth?
year (4 digits)
Yes (1)
If YES, date & time of readmission:
__ __ /__ __ /__ __ __ __
month
AND date of discharge __ __ /__ __ /__ __ __
Unknown (9)
Unknown (9)
Unknown (9)
Yes (1)
__ __ __ __
time
year (4 digits)
__ month / day / year (4 digits)
day
Unknown (9)
time
No (0)
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?
__ __ __ __
Unknown (9)
No (0)
Unknown (9)
Unknown (9)
Yes (1)
7. Was the infant discharge to home and readmitted to a different hospital?
No (0)
If YES, hospital ID: __ __ __ __ __
AND date & time of admission: __ __ /__ __ /__ __ __ __ month / day / year (4 digits) __ __ __ __ time
AND date of discharge __ __ /__ __ /__ __ __ __
month / day / year (4 digits)
Unknown (9)
Unknown (9)
Unknown (9)
8. Outcome of infant :
Unknown (9)
Survived (1) Died (2)
If infant Died, specify Date of Death _ _ / _ _/ _ _ _ _ month / day / year (4 digits)
Unknown (9)
8a. If survived, did the infant have the following neurologic or medical sequelae evident on discharge (Check all that apply)
Requiring oxygen
None
Seizure disorder
Hearing impairment
9. Was the infant admitted to the NICU during hospitalization following birth?
Yes (1)
No (0)
Unknown (9)
9a. If infant readmitted, was infant admitted to NICU during rehospitalization?
Yes (1)
No (0)
Unknown (9)
Unknown (9)
9b. If yes, to either 9 or 9a, total number of days in the NICU. __ __ __
10. From time of birth to date of discharge, did the infant have a
Yes (1)
temperature ≥ 100.4 F/38 C?
* Questions 10a-c: Only for live births of pregnant and post-partum HiNSES cases
No (0)
10a. Were any bacterial cultures performed on infant from time of birth to date of discharge?
Unknown (9)
Yes (1)
No (0)
10b. If cultures performed from time of birth to date of discharge+, list the culture date(s), source(s), and result(s).
+For neonates hospitalized for > 7 days, list cultures from time of birth through day 7 of life
Results
Culture Date
Culture Source
Positive (specify organism) _____________
#1. __ __ / __ __ / __ __ __ __
Blood
CSF
Other (specify)
Negative
_____________
Result unknown
#2. __ __ / __ __ / __ __ __ __
Blood
CSF
Other (specify)
_____________
Page 1 of 4
Positive (specify organism) _____________
Negative
Result unknown
8/2018
Public reporting burden to collect this information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering/maintaining the data
needed, and completing/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 information, including suggestions for reducing this burden to CDC,
Do not send the completed form to this address.
10c. If any sterile site culture positive for Hi, list ABCs State ID assigned to infant case.
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)
None of the codes listed were found in chart
320.0: Haemophilus meningitis
762.7: Chorioamnionitis affecting fetus or newborn
771.81: Septicemia of newborn
670.22 Puerperal sepsis, delivered w/ postpartum
995.91: Sepsis
038.41 Septicemia due to H. influenzae
482.2: Pneumonia due to H. influenzae
Other ICD-9 codes (specify) _________________
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)
P36.9: Bacterial sepsis of newborn, unspecified
None of the codes listed were found in the chart
P02.7:
Chorioamnionitis
A41.3: Sepsis due to H. influenzae
O85: Puerperal sepsis
J14: Pneumonia due to H. influenzae
O75.3: Sepsis during labor
G00.0: Haemophilus meningitis
B96.3 H. influenzae as cause of disease classd elswhr
P36.8: Other bacterial sepsis of newborn
Other ICD-10 codes (specify) _________________
Maternal Information
12. Maternal admission date & time: __ __ /__ __ /__ __ __ __ __ __ __ __
month
day
Not Applicable/
Patient not hospitalized
Unknown (9)
time
year (4 digits)
13. Maternal age at delivery / spontaneous abortion (years): __ __ years
14. Number of prior pregnancies __ __
Unknown (9)
15. Any prior history of preterm births? (< 37 weeks gestation al age)
Yes (1)
16. Did mother receive prenatal care?
No (0)
Yes (1)
No (0)
Unknown (9)
Unknown (9)
17. Please record: the total number of prenatal visits AND the first and last visit dates to the prenatal provider as
recorded in the chart
Unknown (9)
No. of visits: __ __ First visit: __ __ /__ __ /__ __ __ __ Last visit: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
month
day
year (4 digits)
Unknown (9)
18. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
19. Date & time of membrane rupture: __ __ /__ __ /__ __ __ __
month
20. Was duration of membrane rupture
day
year (4 digits)
≥ 18 hours?
time
Yes (1)
21. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?
22. Type of rupture:
Spontaneous (1)
Unknown (9)
__ __ __ __
Artificial (2)
No (0)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
Unknown (9)
22a. If artificial rupture, reason for rupture (check all that apply)
Unknown (9)
Fetal distress
Suspected chorioamnionitis
Preclampsia/eclampsia/hypertension
Maternal bleeding
Gestational diabetes
Severe fetal growth restriction
Post-term pregnancy
Other, specify ___________________
23. Type of delivery: (Check all that apply)
Unknown (9)
8/2018
Vaginal
Forceps
Vaginal after previous C-section (VBAC)
Vacuum
Page 2 of 4
Primary C-section
Repeat C-section
Yes (1)
23a. If delivery was by C-section: Did labor begin before C-section?
23b. If delivery was by C-section: Did membrane rupture happen before C-section?
23c. If delivery by C-section was it scheduled or emergency?
Emergency (2)
Scheduled (1)
24. Did mother have a prior history of penicillin allergy?
IF YES, was a previous maternal history of anaphylaxis noted?
Yes (1)
No (0)
Yes (1)
23d. If emergency C-section. What was the reason? (check all that apply)
Cord prolapse
Placenta previa/abruption
Unknown (9)
Fetal distress
Uterine rupture
Failure to progress
Breech position
25. Were antibiotics given to the mother intrapartum?
Unknown (9)
No (0)
Unknown (9)
Eclampsia/preclampsia/hypertension
Diabetes
Maternal infection
Other(specify) ________________
Yes (1)
No (0)
Yes (1)
No (0)
No (0)
Unknown (9)
Unknown (9)
IF YES, answer 25. a-b and Questions 26-27
a) Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
__ __ __ __
time
Unknown (9)
b)
26.
Interval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)
___ ___ (minutes) ___ ___ (days)*
*Day variable should only be completed if the number of hours >24
27.
What was the reason for administration of intrapartum antibiotics? (Check all that apply)
Unknown (9)
Intrapartum fever (≥ 100.4 F/38 C)
Prolonged latency
C-section prophylaxis
GBS prophylaxis
28. Did mother have chorioamnionitis or suspected chorioamnionitis during
the intrapartum period or in the week prior to spontaneous abortion?
Suspected amnionitis/chorioamnionitis
Mitral valve prolapse prophylaxis
Other (specify) _____________
Yes (1)
No (0)
Unknown (9)
29. During the intrapartum period or in the week prior to spontaneous abortion did the mother have any of the following
symptoms or diagnoses? (check all that apply)
Maternal tachycardia (>100 beats/min)
Uterine tenderness
Fetal
tachycardia (>160 beats/min)
Unknown (9)
Foul smelling amniotic fluid
Intrapartum fever (≥ 100.4 F/38 C)
None listed
Urinary tract infection
Maternal WBC >20 or 20,000
8/2018
Page 3 of 4
30. Maternal Intrapartum fever (T ≥ 100.4 F or 38.0 C):
IF YES, 1 recorded T
st
Yes (1)
No (0)
≥ 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month
day
year (4 digits)
Unknown (9)
Unknown (9)
__ __ __ __
time
30a. Were any bacterial cultures performed on mother during labor/end of pregnancy?
Yes (1)
No (0)
30b. If cultures performed during labor/end of pregnancy, list the culture date(s) during labor, source(s), and result(s)?
Culture Date
Culture Source
Results
#1. __ __ / __ __ / __ __ __ __
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
30c. If any sterile site cultures collected during labor/end of pregnancy were positive for H. Influenzae,
list ABCs State ID assigned to maternal case. __ __ __ __ __ __ __
31. Maternal post-partum fever (temperature ≥ 100.4 F/38 C)?
Yes (1)
No (0)
Unknown (9)
31a. Were any bacterial cultures performed on mother post-partum/post pregnancy loss?
Yes (1)
No (0)
31b. If cultures performed post-partum/post pregnancy loss, list the culture date(s), source(s) and result(s).
Results
Culture Date
Culture Source
Blood
Vaginal
Urine Cervical Positive (specify organism) _____________
#1. __ __ / __ __ / __ __ __ __
Negative
Placental Amniotic Fluid
Result unknown
Other (specify) _____________
#2. __ __ / __ __ / __ __ __ __
Blood
Placental
Vaginal
Urine
Amniotic Fluid
Cervical
Other (specify) _____________
31c.
Positive (specify organism) _____________
Negative
Result unknown
If any sterile site cultures collected post-partum/post pregnancy loss were positive for
+LQIOXHQ]DH, list ABCs State ID assigned to maternal case. __ __ __ __ __ __ __
31d. Were any ICD-9 or ICD-10 codes reported in the discharge diagnoses of the mother’s chart?
Yes (1)
(
No (0)
Unknown (9)
31e. If any ICD-9 or ICD-10 codes reported in the discharge diagnoses of the mother’s chart: (Check all that apply)
ICD-9
ICD-10
None of the listed ICD-9 codes found in chart
None of the listed ICD-10 codes found in chart
A41.3: Sepsis due to H. influenzae
995.91: Sepsis
J14: Pneumonia due to H. influenzae
038.41 Septicemia due to H. influenzae
G00.0: Haemophilus meningitis
482.2: Pneumonia due to H. influenzae
P02.7: Chorioamnionitis
320.0: Haemophilus meningitis
O85: Puerperal sepsis
762.7: Chorioamnionitis affecting fetus or newborn
O75.3: Sepsis during labor
670.22: Puerperal sepsis, delivered, w/ postpartum
B96.3 H. influenzae as cause of disease classd elswhr
670.20: Puerperal sepsis, unspecified
Other ICD-10 codes (specify) _________________
670.24: Puerperal sepsis, postpartum
Other ICD-9 codes (specify)____________________
32. COMMENTS: ______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
33. HiNSES Form Tracking Status
8/2018
Complete (1)
Partial (2)
Page 4 of 4
Chart unavailable (3)
Edited & corrected (4)
| File Type | application/pdf |
| File Title | HiNSES CRF.pdf |
| File Modified | 2018-08-07 |
| File Created | 2012-11-15 |