Form CDPH9049 "California Congenital Syphilis (Cs) Case Investigation and Report" - California

What Is Form CDPH9049?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the California Department of Public Health;
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Download Form CDPH9049 "California Congenital Syphilis (Cs) Case Investigation and Report" - California

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State of California—Health and Human Services Agency
California Department of Public Health
CASE ID No.:
Mother's Name:
Mother's CalREDIE ID#:
Delivery
Infant's Name:
Infant's CalREDIE ID#:
Hospital:
CALIFORNIA CONGENITAL SYPHILIS (CS) CASE INVESTIGATION AND REPORT
Part I: MATERNAL INFORMATION
4. Country of residence:
2. Reporting state:
3. Reporting county:
1. Report date to health department:
Unk
(leave blank if USA)
/
/
CALIFORNIA
Mo.
Day
Yr.
6. Residence county:
8. Residence zip code:
7. Residence city:
Unk
5. Residence state:
Unk
Unk
Unk
(if case resides in a city health jurisdiction)
9. Mother's date of birth:
10. Mother's ethnicity:
11. Mother's race:
(check all that apply)
Unk
Hispanic/Latina
Unk
American Indian/Alaska Native
Asian
Black or African American
/
/
Non-Hispanic/Non-Latina
Native Hawaiian or Other Pacific Islander
White
Unk
Mo.
Day
Yr.
15. Did mother have a non-treponemal test (e.g.,
12. Did mother have prenatal care?
13. Indicate date of first prenatal visit:
14. Indicate number of prenatal visits:
RPR or VDRL) in pregnancy, at delivery, or within
Yes, at least once
/
/
No (Go to Q15)
3 days of delivery?
Unk
Unk
in US
Mo.
Day
Yr.
Yes
No (Go to Q17)
Unk (Go to Q17)
Yes, outside of US
Unk (Go to Q15)
16. Indicate dates and results of non-treponemal tests: (list the most recent first)
17. Did mother have confirmatory treponemal test result (e.g., EIA, TP-PA)?
If so, when was the test performed?
Date
Results
Titer
Yes, reactive
Yes, nonreactive
No test
Mo.
Day
Yr.
/
/
/
/
1:
Unk
a.
Unk
Reactive
Nonreactive
Unk
Mo.
Day
Yr.
/
/
1:
b.
Unk
Reactive
Nonreactive
Unk
18. Did mother have darkfield or direct fluorescent antibody (DFA) exam
/
/
of lesions at delivery?
1:
c.
Unk
Reactive
Nonreactive
Unk
Yes, positive
No test of lesions
Unk
/
/
1:
d.
Reactive
Nonreactive
Unk
Unk
Yes, negative
No lesions present
19. Before this delivery, when was mother last treated for syphilis?
20. Before pregnancy, was mother's treatment adequate?
/
/
Yes, adequate: treatment appropriate for stage
Before pregnancy (Go to Q20)
No treatment (Go to Q22)
Unk (Go to Q22)
Mo.
Day
Yr.
(Go to Q22)
During pregnancy (Go to Q21)
Unk (Go to Q22)
No, treatment not appropriate for stage (Go to Q22)
21. During pregnancy, was mother's treatment adequate? (Footnote a)
Yes, adequate: penicillin-based
No, inadequate: penicillin-based
No, inadequate: penicillin-based treatment
No, inadequate: non-penicillin-
Unk
treatment appropriate for stage
treatment not appropriate for stage
begun < 30 days before delivery
based treatment
Part II: INFANT INFORMATION
23. Vital status:
24. Date of death:
22. Date of delivery:
Alive (Go to Q25)
Stillborn (Go to Q26) (Footnote b)
/
/
/
/
Unk
Unk
Born alive, then died
Unk (Go to Q25)
Mo.
Day
Yr.
Mo.
Day
Yr.
25. Sex:
26. Birthweight (in grams):
27. Estimated gestational age (in weeks)
Male
Female
Unk
Unk
Unk
28. a) Did infant/child have a reactive
b) When was the infant/child's
c) Indicate titer of infant/child's
29. a) Did infant/child have a
b) When was the infant/child's first
non-treponemal test for syphilis
first reactive non-treponemal
first reactive non-treponemal
reactive treponemal test
reactive treponemal test for
(e.g., VDRL, RPR)?
test for syphilis?
test for syphilis?
for syphilis (e.g., EIA, TP-PA)?
syphilis?
Yes, serum reactive
Yes, serum reactive
/
/
/
/
1:
Yes, cord blood reactive
Yes, cord blood reactive
Mo.
Day
Yr.
Mo.
Day
Yr.
No, result non-reactive
No, result non-reactive
Not tested
Unk
Not tested
Unk
30. Did the Infant/child have any classic signs of congenital syphilis? (Footnote c)
31. Did the Infant/child have a darkfield exam or DFA-TP?
LABORATORY
CONFIRMATION:
Yes
No, asymptomatic infant/child
Unk
Yes, positive
Yes, negative
No test
Unk
INFANT EVALUATION
33. Did the infant/child have a
34. Did the infant/child have a CSF cell
35. Was the infant/child treated?
CSF-VDRL?
count or CSF protein test? (Footnote d)
32. Did the infant/child have long bone
Yes, with Aqueous or
Yes, with other
X-rays?
treatment
Yes, one or both
Procaine Penicillin for
Yes, reactive
No test
No test
≥10 days
Yes, changes
elevated
No treatment
No x-rays
consistent with CS
Yes, with Benzathine
Yes, nonreactive
Unk
Yes, both not
Unk
Unk
penicillin x 1
elevated
Yes, no signs of CS
Unk
Part III: CONGENITAL SYPHILIS CASE CLASSIFICATION
36. Classification
Confirmed case (Laboratory confirmed identification of T.pallidum, e.g.,
Syphilitic stillbirth
Probable case (A case identified by the above algorithm,
Not a case
darkfield or direct fluorescent antibody positive lesions)
(Footnote b)
which is not a confirmed case or syphilitic stillbirth)
Reporting of STDs does not require patient consent and is not subject to the requirements of the Health Insurance Portability and Accountability Act (HIPAA). HIPPA allows disclosure of this
information to public health for the “purpose of ... public health surveillance, public health investigations, and public health interventions...” 45 CFR §164.512(b)(1)
CDPH 9049 (3/2017)
(CS Case Report 3/30/2017)
State of California—Health and Human Services Agency
California Department of Public Health
CASE ID No.:
Mother's Name:
Mother's CalREDIE ID#:
Delivery
Infant's Name:
Infant's CalREDIE ID#:
Hospital:
CALIFORNIA CONGENITAL SYPHILIS (CS) CASE INVESTIGATION AND REPORT
Part I: MATERNAL INFORMATION
4. Country of residence:
2. Reporting state:
3. Reporting county:
1. Report date to health department:
Unk
(leave blank if USA)
/
/
CALIFORNIA
Mo.
Day
Yr.
6. Residence county:
8. Residence zip code:
7. Residence city:
Unk
5. Residence state:
Unk
Unk
Unk
(if case resides in a city health jurisdiction)
9. Mother's date of birth:
10. Mother's ethnicity:
11. Mother's race:
(check all that apply)
Unk
Hispanic/Latina
Unk
American Indian/Alaska Native
Asian
Black or African American
/
/
Non-Hispanic/Non-Latina
Native Hawaiian or Other Pacific Islander
White
Unk
Mo.
Day
Yr.
15. Did mother have a non-treponemal test (e.g.,
12. Did mother have prenatal care?
13. Indicate date of first prenatal visit:
14. Indicate number of prenatal visits:
RPR or VDRL) in pregnancy, at delivery, or within
Yes, at least once
/
/
No (Go to Q15)
3 days of delivery?
Unk
Unk
in US
Mo.
Day
Yr.
Yes
No (Go to Q17)
Unk (Go to Q17)
Yes, outside of US
Unk (Go to Q15)
16. Indicate dates and results of non-treponemal tests: (list the most recent first)
17. Did mother have confirmatory treponemal test result (e.g., EIA, TP-PA)?
If so, when was the test performed?
Date
Results
Titer
Yes, reactive
Yes, nonreactive
No test
Mo.
Day
Yr.
/
/
/
/
1:
Unk
a.
Unk
Reactive
Nonreactive
Unk
Mo.
Day
Yr.
/
/
1:
b.
Unk
Reactive
Nonreactive
Unk
18. Did mother have darkfield or direct fluorescent antibody (DFA) exam
/
/
of lesions at delivery?
1:
c.
Unk
Reactive
Nonreactive
Unk
Yes, positive
No test of lesions
Unk
/
/
1:
d.
Reactive
Nonreactive
Unk
Unk
Yes, negative
No lesions present
19. Before this delivery, when was mother last treated for syphilis?
20. Before pregnancy, was mother's treatment adequate?
/
/
Yes, adequate: treatment appropriate for stage
Before pregnancy (Go to Q20)
No treatment (Go to Q22)
Unk (Go to Q22)
Mo.
Day
Yr.
(Go to Q22)
During pregnancy (Go to Q21)
Unk (Go to Q22)
No, treatment not appropriate for stage (Go to Q22)
21. During pregnancy, was mother's treatment adequate? (Footnote a)
Yes, adequate: penicillin-based
No, inadequate: penicillin-based
No, inadequate: penicillin-based treatment
No, inadequate: non-penicillin-
Unk
treatment appropriate for stage
treatment not appropriate for stage
begun < 30 days before delivery
based treatment
Part II: INFANT INFORMATION
23. Vital status:
24. Date of death:
22. Date of delivery:
Alive (Go to Q25)
Stillborn (Go to Q26) (Footnote b)
/
/
/
/
Unk
Unk
Born alive, then died
Unk (Go to Q25)
Mo.
Day
Yr.
Mo.
Day
Yr.
25. Sex:
26. Birthweight (in grams):
27. Estimated gestational age (in weeks)
Male
Female
Unk
Unk
Unk
28. a) Did infant/child have a reactive
b) When was the infant/child's
c) Indicate titer of infant/child's
29. a) Did infant/child have a
b) When was the infant/child's first
non-treponemal test for syphilis
first reactive non-treponemal
first reactive non-treponemal
reactive treponemal test
reactive treponemal test for
(e.g., VDRL, RPR)?
test for syphilis?
test for syphilis?
for syphilis (e.g., EIA, TP-PA)?
syphilis?
Yes, serum reactive
Yes, serum reactive
/
/
/
/
1:
Yes, cord blood reactive
Yes, cord blood reactive
Mo.
Day
Yr.
Mo.
Day
Yr.
No, result non-reactive
No, result non-reactive
Not tested
Unk
Not tested
Unk
30. Did the Infant/child have any classic signs of congenital syphilis? (Footnote c)
31. Did the Infant/child have a darkfield exam or DFA-TP?
LABORATORY
CONFIRMATION:
Yes
No, asymptomatic infant/child
Unk
Yes, positive
Yes, negative
No test
Unk
INFANT EVALUATION
33. Did the infant/child have a
34. Did the infant/child have a CSF cell
35. Was the infant/child treated?
CSF-VDRL?
count or CSF protein test? (Footnote d)
32. Did the infant/child have long bone
Yes, with Aqueous or
Yes, with other
X-rays?
treatment
Yes, one or both
Procaine Penicillin for
Yes, reactive
No test
No test
≥10 days
Yes, changes
elevated
No treatment
No x-rays
consistent with CS
Yes, with Benzathine
Yes, nonreactive
Unk
Yes, both not
Unk
Unk
penicillin x 1
elevated
Yes, no signs of CS
Unk
Part III: CONGENITAL SYPHILIS CASE CLASSIFICATION
36. Classification
Confirmed case (Laboratory confirmed identification of T.pallidum, e.g.,
Syphilitic stillbirth
Probable case (A case identified by the above algorithm,
Not a case
darkfield or direct fluorescent antibody positive lesions)
(Footnote b)
which is not a confirmed case or syphilitic stillbirth)
Reporting of STDs does not require patient consent and is not subject to the requirements of the Health Insurance Portability and Accountability Act (HIPAA). HIPPA allows disclosure of this
information to public health for the “purpose of ... public health surveillance, public health investigations, and public health interventions...” 45 CFR §164.512(b)(1)
CDPH 9049 (3/2017)
(CS Case Report 3/30/2017)
CALIFORNIA CONGENITAL SYPHILIS (CS) CASE INVESTIGATION AND REPORT ALGORITHM
Footnotes:
a. Adequate treatment in adults is defined in the STD Treatment Guidelines (cdc.gov/std/treatment/). In pregnancy,
primary, secondary or early latent cases should be treated with Benzathine Penicillin G 2.4 million units IM
administered 30 days or more prior to delivery; late latent cases and latent cases of unknown duration should be
treated with Benzathine Penicillin G, 7.2 million units, administered as 3 doses of 2.4 million units IM each, at one
week intervals, with the first dose administered 30 days or more prior to delivery and all doses received.
b. A syphilitic stillbirth is a fetal death in which the mother had untreated or inadequately treated syphilis at the time of
delivery of either a fetus after a 20-week gestation or a fetus weighing > 500 grams.
c. Signs of congenital syphilis (usually in an infant or child < 2 years old) include: condyloma lata, snuffles, syphilitic skin
rash, hepatosplenomegaly, jaundice/hepatitis, pseudoparalysis, or edema (nephrotic syndrome and/or malnutrition).
Stigmata in an older child might include: interstitial keratitis, nerve deafness, anterior bowing of shins, frontal
bossing, mulberry molars, Hutchinson’s teeth, saddle nose, rhagades, or Clutton’s joints.
d. Cerebrospinal fluid (CSF) cell count and protein vary with gestational age. For infants 30 days old or less, CSF white
blood cell (WBC) count > 15 WBC/mm
3
and CSF protein > 120 mg/DL are considered abnormal. Beyond the neonatal
period, a CSF cell count of > 5 white blood cells/mm
or a CSF protein > 40 mg/DL is abnormal, regardless of CSF
3
serology.
e. See the national case definition for syphilis:
www.cdc.gov/osels/ph_surveillance/nndss/casedef/syphilis1990.htm
CDPH 9049 (3/2017)
(CS Case Report 3/30/2017) Back
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