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NEONATAL INFECTION EXPANDED TRACKING FORM
*Infant’s Name: _______________________________________________________________________________
*Infant’s Chart No.: _____________________________________________
(Last, First, M.I.)
*Mother’s Name: _______________________________________________________________________________
(Last, First, M.I.)
*Mother’s Chart No.: ____________________________________________
*Mother’s Date of Birth: __ __ /__ __ /__ __ __ __
*Hospital Name: _________________________________________
month day year (4 digits)
ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs)
NEONATAL INFECTION EXPANDED TRACKING FORM
STATEID __ __ __ __ __ __ __
HOSPITAL ID (of birth; if home birth leave blank) __ __ __ __ __
Infant Information
Were labor & delivery records available?
Yes (1)
Date & time of positive culture: __ __ /__ __ /__ __ __ __
__ __ __ __
month
day
year (4 digits)
No (0)
Form Approved
0920-0978
(times in military format)
2. Did this birth occur outside of the hospital?
month
day
year (4 digits)
Yes (1)
No (0)
Unknown (9)
Home Birth (1)
IF
YES,
please
check
one:
Time of birth: ___ ___ ___ ___
Unknown (1)
1. Date of Birth: __ __ /__ __ /__ __ __ __
Birthing Center (2)
Other (4)
En route to hospital (3)
time
Unknown (9)
3a. Gestational age of infant at 3b. Date of maternal last menstrual 3c. Gestational age determined by:
period (LMP):
birth in completed weeks:
Unknown (1)
Dates (1)
Physical Exam (2)
Ultrasound (3)
__ __ /__ __ /__ __ __ __
__ __ (do not round up)
Unknown (9)
Assisted Reproductive Technology (4)
month
day
year (4 digits)
5. Date & time of newborn discharge from hospital of birth:
4. Birth weight:
___ lbs ___oz
OR
6. Was patient admitted to the
ICU during hospitalization?
Yes
es ((1)
No (0)
__ __ /__ __ /__ __ __ __
__ __ __ __ grams
Unknown (9)
month
day
__ __ __ __
year (4 digits)
Unknown (1)
time
IF YES,
Date & time of admission: __ __ /__ __ /__ __ __ __
__ __ __ __
Unknown (1)
__ __ /__ __ /__ __ __ __
__ __ __ __
Unknown (1)
month
Date & time of discharge:
month
day
day
year (4 digits)
year (4 digits)
time
time
***Questions 7-10b should only be completed for early- and late-onset GBS cases***
7. Was the infant discharged to home and readmitted to the birth hospital?
IF YES, date & time of readmission: __ __ /__ __ /__ __ __ __
month
day
Yes (1)
__ __ __ __
time
year (4 digits)
8. Was the infant admitted to a different hospital from home?
Yes (1)
No (0)
Unknown (1)
No (0)
IF YES, hospital ID: ___ ___ ___ ___ ___
AND date & time of admission: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
__ __ __ __
time
Unknown (1)
9a. Were any ICD-10 codes reported in the discharge diagnosis of the infant’s chart?
Yes (1)
No (0)
Unknown (9)
9b. IF YES, were any of the following ICD-10 codes reported in the discharge diagnosis of the chart? (Check all that apply)
A40.1: Sepsis due to streptococcus, group B (1)
A40.8: Other Streptococcal sepsis (1)
A40.9: Streptococcus sepsis, unspecified (1)
A49.1: Streptococcal infection, unspecified site (1)
P36: Bacterial sepsis of newborn (1)
P36.0: Sepsis of newborn due to streptococcus, group B (1)
P36.1: Sepsis of newborn to other unspecified streptococci (1)
P36.9: Bacterial sepsis of newborn, unspecified (1)
B95.1: Streptococcus, group b as the cause of disease classified elsewhere (1)
B95.5: Unspecified streptococcus as the cause of disease classified elsewhere (1)
G00.2: Streptococcal meningitis (1)
10. Did the baby receive breast milk from the mother? (for late-onset GBS cases only):
Yes (1)
No (0)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
10a. Did the infant receive antibiotics anytime during the birth hospitalization?
Yes (1)
No (0)
Unknown (9)
10b. IF YES, was it a beta-lactam?
Yes (1)
No (0)
Unknown (9)
IF YES, did the baby receive breast milk before onset of GBS
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 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). Do not send the completed form to this address.
9/2024
Page 1 of 4
Maternal Information
__ __ __ __
11. Maternal admission date & time: __ __ /__ __ /__ __ __ __
month
day
year (4 digits)
12. Maternal age at delivery (years): __ __ years
13. Maternal blood type:
A (1)
B (2)
Unknown (9)
AB (3)
Unknown (1)
time
12a. Number of prior pregnancies __ __
Unknown (9)
14. Did mother have a prior history of penicillin allergy?
O (4)
IF YES, was a previous maternal history of anaphylaxis noted?
14a. MATERNAL UNDERLYING OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE, check appropriate box)
Immunoglobulin Deficiency
1
1
AIDS or CD4 count <200
1
Complement Deficiency
1
Immunosuppressive Therapy (Steroids, etc.)
1
1
Asthma
1
Connective Tissue Disease (Lupus, etc.)
1
Leukemia
1
1
Atherosclerotic CVD (ASCVD)/CAD 1
1
CSF Leak
Multiple Myeloma
1
1
Bone Marrow Transplant (BMT)
1
Dementia
1
Multiple Sclerosis
1
CVA/Stroke/TIA
1
1
Diabetes Mellitus,
1
Myocardial Infarction
1
Chronic Hepatitis C
1
1
HbA1C ______(%), Date ___/___/______
Nephrotic Syndrome
1
1
Chronic Kidney Disease
1
Emphysema/COPD
1
1
Neuromuscular Disorder
1
Chronic Liver Disease/cirrhosis
1
Heart Failure/CHF
1
Obesity
1
Current Chronic Dialysis
1
HIV
Infection
1
1
Parkinson’s Disease
Chronic Skin Breakdown
1
Hodgkin’s Disease/Lymphoma
1
1
Peptic Ulcer Disease
15. Date & time of membrane rupture: __ __ /__ __ /__ __ __ __
month
day
__ __ __ __
year (4 digits)
Yes (1)
No (0)
Yes (1)
No (0)
1
None
1
Unknown
Peripheral Neuropathy
Peripheral Vascular Disease
Plegias/Paralysis
Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Unknown (1)
time
16. Was duration of membrane rupture >18 hours?
Yes (1)
No (0)
Unknown (9)
17. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?
Yes (1)
No (0)
Unknown (9)
18. Type of rupture:
Spontaneous (1)
Artificial (2)
Unknown (9)
19. Type of delivery: (Check all that apply)
If delivery was
by C-section:
Vaginal (1)
Vaginal after previous C-section (1)
Primary C-section (1)
Forceps (1)
Vacuum (1)
Unknown (1)
Did labor begin before C-section?
Yes (1)
No (0)
Unknown (9)
Did membrane rupture happen before C-section?
Yes (1)
No (0)
Unknown (9)
20. Intrapartum fever (T > 100.4 F or 38.0 C):
Yes (1)
No (0)
IF YES, 1st recorded T > 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month
21.
Repeat C-section (1)
Were antibiotics given to the mother intrapartum?
day
year (4 digits)
Yes (1)
Unknown (9)
Unknown (1)
__ __ __ __
time
No (0)
Unknown (9)
IF YES, answer 21a-b and Questions 22-23
a) Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __
month
b) Antibiotic 1: ___________________________
Start date: __ __ /__ __ /__ __ __ __
9/2024
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 2 of 4
22.
Interval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)
___ ___ (minutes) ___ ___ (days)*
*Day variable should only be completed if the number of hours >24
23.
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)
24. Did mother have chorioamnionitis or suspected chorioamnionitis?
No (0)
Unknown (9)
***Questions 25–33 should only be completed for early- and late-onset GBS cases***
25. Did mother receive prenatal care?
Yes (1)
No (0)
Unknown (9)
26. 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)
27. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
28. GBS bacteriuria during this pregnancy?
Yes (1)
No (0)
Unknown (9)
IF YES, what order of magnitude was the colony count?
0 (1)
<10,000 (2)
10k–<25,000 (3)
25k–<50,000 (4)
50k–<75,000 (5)
>100,0000 (7)
Unknown (9)
29. Previous infant with invasive GBS disease?
Yes (1)
No (0)
Unknown (9)
30. Previous pregnancy with GBS colonization?
Yes (1)
No (0)
Unknown (9)
75k–<100,000 (6)
31a. Was maternal group B strep colonization screened for BEFORE admission (in prenatal care)?
Yes (1)
No (0)
Unknown (9)
IF YES, list dates, test type, and test results below:
Test date
:
1. __ __ /__ __ /__ __ __ __
2. __ __ /__ __ /__ __ __ __
Test Result
(Do not include urine here!)
Test type:
Culture (1)
PCR (2)
Rapid antigen (3)
Positive (1)
Other (4)
Unknown (9)
Unknown (9)
Culture (1)
PCR (2)
Other (4)
Unknown (9)
Positive (1)
Unknown (9)
Rapid antigen (3)
Negative (0)
Negative (0)
31b. If the most recent test was GBS positive was antimicrobial susceptibility performed BEFORE admission (in prenatal care)?
Yes (1)
No (0)
Unknown (9)
IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?
Yes (1)
No (0)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
32a. Was maternal group B strep colonization screened for AFTER admission (before delivery)?
Yes (1)
No (0)
Unknown (9)
IF YES, list date of most recent test, test type and test results below:
Test date
__ __ /__ __ /__ __ __ __
9/2024
:
Test type:
Culture (1)
PCR (2)
Rapid antigen (3)
Other (4)
Unknown (9)
Page 3 of 4
Test Result
(Do not include urine here!)
Positive (1)
Unknown (9)
Negative (0)
32b. If the most recent test was GBS positive, was antimicrobial susceptibility performed AFTER admission?
Yes (1)
No (0)
Unknown (9)
IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?
33.
Yes (1)
Yes (1)
No (0)
No (0)
Were GBS test results available to care givers at the time of delivery?
Unknown (9)
Unknown (9)
Yes (1)
No (0)
Unknown (9)
34. COMMENTS: ______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
35.
9/2024
Neonatal Infection Expanded Form Tracking Status:
Incomplete (2)
Edited & corrected (3)
Complete (1)
Page 4 of 4
Chart unavailable after 3 requests (4)
| File Type | application/pdf |
| File Title | ABCs 2014 Extended Neonatal Infection CRF_no_OMB updated.pdf |
| File Modified | 2024-09-17 |
| File Created | 2024-09-17 |