PART 1: MATERNAL Name DOB EDC BIRTHING HOSPITAL ADDRESS ETHNICITY COUNTY PHONE NUMBER DATE OF HBsAg TESTING STATE HBsAg TEST RESULT PHONE( H) MOTHER’S INSURANCE TYPE MD PHONE (C) MD PHONE NUMBER PHONE (W) LANGUAGE SPOKEN PART 2: HOUSEHOLD/SEXUAL CONTACTS PART 3: INFANT # OF HOUSEHOLD CONTACTS: NAME DOB WEIGHT # RECEIVING PREVACCINATION SEROLOGIC ADDRESS: TESTING COUNTY # HBsAg (+) # IMMUNE TO HBV STATE #SUSCEPTIBLE #VACCINATED THIS PREGNANCY MD FOR VACCINATIONS/ PHONE NUMBER VACCINATIONS/ POSTVACCINATION SEROLOGY RESULTS Part 4: INFANT’S DATE OF HBIG HEPATITIS B SURFACE ANTIGEN (HBsAg) DATE OF HEPATITIS VACCINE/BRAND ANTIBODY TO HEPATITIS B SURFACE ANTIGEN (Anti-HBs) QUANTITATIVE – REPEATED RESULTS, IF NEEDED HBsAg Anti-HBs PART 5 CASE NOTES
PART 1: MATERNAL Name ADDRESS DATE OF HBsAg TESTING HBsAg TEST RESULT MD MD PHONE NUMBER DOB ETHNICITY COUNTY STATE PHONE( H) PHONE (C) PHONE (W) EDC BIRTHING HOSPITAL PHONE NUMBER MOTHER’S INSURANCE TYPE LANGUAGE SPOKEN PART 2: HOUSEHOLD/SEXUAL CONTACTS PART 3: INFANT # OF HOUSEHOLD CONTACTS: # RECEIVING PREVACCINATION SEROLOGIC TESTING # HBsAg (+) # IMMUNE TO HBV #SUSCEPTIBLE #VACCINATED THIS PREGNANCY NAME DOB WEIGHT ADDRESS: COUNTY STATE MD FOR VACCINATIONS/ PHONE NUMBER Part 4: INFANT’S VACCINATIONS/ POSTVACCINATION SEROLOGY RESULTS DATE OF HBIG DATE OF HEPATITIS VACCINE/BRAND HEPATITIS B SURFACE ANTIGEN (HBsAg) ANTIBODY TO HEPATITIS B SURFACE ANTIGEN (Anti-HBs) – QUANTITATIVE REPEATED RESULTS, IF NEEDED HBsAg Anti-HBs PART 5 CASE NOTES
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