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: 2/16/2007
OMB No. 0920-0128
Expiration Date: 2/28/2010
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)
Attachment 3a
Congenital Syphilis (CS) Case Investigation and Report 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
1. Report date to health department
2. Reporting state
3. Reporting county
4. Other geographic unit (optional)
5. Country of residence
6. State
7. Residence county
8. Residence zip code
9. Mother’s date of birth
10. Mother’s ethnicity
11. Mother’s race
12. Mother’s marital status
13. Last menstrual period (before delivery)
14. Did mother have prenatal care?
15. Data of first prenatal visit
16. Number of prenatal visits
17. Did mother have a non-treponemal test in
pregnancy, at delivery, or soon after delivery
within 3 Days?
18. Dates and results of non-treponemal tests
19. Did mother have confirmatory treponemal test
result?
20. Did mother have darkfield or direct fluorescent
antibody (DFA) exam of lesions at delivery?
21. Before this delivery, when was mother last treated
for syphilis?
22. Before pregnancy, was mother’s treatment adequate?
23. During pregnancy, was mother’s treatment adequate?
24. Was there an appropriate serologic response?
Part II – Infant/Child Information
25. Date of Delivery
26. Vital status
27. Date of death
28. Gender
29. Birth weight
30. Estimated gestational age
31. 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.
32. a) Did infant/child have a reactive treponemal
test for syphilis?
b) When was infant/child’s first reactive
treponemal test for syphilis?
33. Did infant/child have any classic signs of CS?
34. Did infant/child have a darkfield exam or DFA-TP?
35. Did infant/child have an IgM-specific treponemal
test?
36. Did infant/child have long bone X-rays?
37. Did infant/child have a CSF-VDRL?
38. Did infant/child have a CSF cell count or CSF
protein test?
39. Was infant/child treated?
Part III – Congenital Syphilis Case Classification
40. 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 Address
Mother’s Phone Number
Mother’s Chart Number
Infant’s Name
Infant’s Chart Number
Delivering Physician
Physician’s Phone Number
Pediatrician
Pediatrician’s Phone Number
| File Type | application/msword |
| Author | gks7 |
| Last Modified By | ziy6 |
| File Modified | 2010-02-02 |
| File Created | 2010-02-02 |