Form CDPH4427 "Confidential Case Report of a Birth Defect in a Fetus or Infant Less Than One Year of Age" - California

What Is Form CDPH4427?

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 November 1, 2015;
  • The latest edition provided by the California Department of Public Health;
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Download Form CDPH4427 "Confidential Case Report of a Birth Defect in a Fetus or Infant Less Than One Year of Age" - California

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California Department of Public Health
State of California - Health and Human Services Agency
Genetic Disease Screening Program
Confidential Case Report of a Birth Defect
In a Fetus or Infant Less than One Year of Age
INSTRUCTIONS
In accordance with State of California law (California Code of Regulations, Title 17, Sections 6531 & 6532), report neural tube defects (NTDs) and/or
chromosomal abnormalities found in fetuses or infants less than one year of age to the California Genetic Disease Screening Program (GDSP) within 30
Genetic Disease Screening Program
days of initial diagnosis.
850 Marina Bay Parkway
Reportable neural tube defects (NTDs) are outlined by ICD-10-CM Codes Q00.0-Q01.9, Q05.0-Q05.9, Q07.0-Q07.03.
Room F-175, Mailstop 8200
Reportable chromosomal abnormalities are outlined by ICD-10-CM Codes Q90.0-Q99.9, excluding Q97.3, Q98.3, Q99.1, and Q99.2.
Submit a separate form for each individual specimen and for each fetus or infant in a multiple gestation.
Richmond, CA 94804
Report the simultaneous occurrence of a neural tube defect and a chromosomal abnormality for the same patient on one single form.
Print clearly in ink or type using UPPER CASE.
(510) 412-1560 (FAX)
Fill bubbles completely when marking.
INFORMATION ABOUT THE MOTHER
1. LAST NAME
2. FIRST NAME
3. MIDDLE INITIAL
4. MAIDEN NAME / AKA / OTHER NAMES USED FOR MOTHER
5. PRENATAL ACCESSION NUMBER (if mother participated in the California Prenatal Screening Program)
6. DATE OF BIRTH (MM/DD/YYYY)
7. APPROXIMATE AGE AT EDD (if date of birth is unknown)
8. SOCIAL SECURITY NUMBER
9. STREET ADDRESS (include apartment number)
10. CITY
11. STATE
12. ZIP CODE
13. MOTHER’S RACE / ETHNICITY (mark all that apply)
Asian Indian
Chinese
Hawaiian
Korean
Native American
White
Other (specify)
Black
Filipino
Hispanic
Laotian
Samoan
Unknown
Guamanian
Japanese
Middle Eastern
Vietnamese
Other Southeast Asian
Cambodian
INFORMATION ABOUT THE INFANT
14. LAST NAME
15. FIRST NAME
16. OTHER NAMES USED FOR INFANT (including father’s last name, if known)
17. DATE OF BIRTH (MM/DD/YYYY)
18. GENDER
19. FETUS LETTER CODE (A, B, C, etc.)
20. BIRTHWEGHT OF INFANT
21. IF DECEASED, DATE OF EXPIRATION (MM/DD/YYYY)
grams
INFORMATION ABOUT THE REPORTING SOURCE
22. LAST NAME (of person completing this form)
23. FIRST NAME (of person completing this form)
24. DATE FORM COMPLETED (MM/DD/YYYY)
25. TELEPHONE NUMBER (including extension)
ext
26. FACILITY TYPE
27. FACILITY NAME AND ADDRESS
Cytogenetic Laboratory
PDC (please provide PDC code)
Other (specify)
Hospital
MD
INFORMATION ABOUT THE PREGNANCY
28. LMP / LAST MENSTRUAL PERIOD (MM/DD/YYYY)
33. DATE OF PREGNANCY STATUS (MM/DD/YYYY)
32. PREGNANCY STATUS
Continuing Pregnancy
Elective Termination
29. EDD / ESTIMATED DATE OF DELIVERY (MM/DD/YYYY)
34. GESTATIONAL AGE AT TIME OF STATUS
Fetal Demise / SAB / Stillbirth / Missed Abortion
Pregnancy Completed with a Livebirth
weeks/days
Selective Reduction
30. # OF FETUSES IN PREGNANCY (including fetal demises)
Unknown / Lost to Follow-Up
35. METHOD USED TO DETERMINE GESTATIONAL AGE
Other (specify)
LMP
31. # OF FETUSES IN PREGNANCY WITH A BIRTH DEFECT
Physical Exam
Ultrasound
PRIVACY STATEMENT: The Information Practices Act of 1977 (Civil Code 1798 et. seq.) requires that the following details be provided when a form is used to obtain information from individuals. The data requested in this form are required by
the Genetic Disease Screening Program (GDSP) of the California Department of Public Health and are mandated by California Code of Regulations, Title 17, Section 6532. These data are used to provide information to subjects on the
prevention of birth defects, to determine the prevalence of neural tube defects and chromosomal abnormalities, and to monitor trends of occurrence. These data will also be used to determine the effectiveness of the California Expanded Alpha
Fetoprotein (AFP) Screening Program. It is mandatory that health professionals completing this form provide complete and accurate information. The records maintained by the GDSP are confidential, as defined in Civil Code 1798.34, and are
exempt from access by any individual, except licensed medical personnel designated by the subject. The information may also be used in special studies, as defined in Health and Safety Code 100330. The furnishing of such information to the
Department or its authorized representative or any other cooperating individual, agency, or organization in any such special study shall not subject any person, hospital, or other organization furnishing such information to any actions or
damages.
CDPH 4427 (11/2015)
Page 1 of 2
(Page 2 on reverse)
California Department of Public Health
State of California - Health and Human Services Agency
Genetic Disease Screening Program
Confidential Case Report of a Birth Defect
In a Fetus or Infant Less than One Year of Age
INSTRUCTIONS
In accordance with State of California law (California Code of Regulations, Title 17, Sections 6531 & 6532), report neural tube defects (NTDs) and/or
chromosomal abnormalities found in fetuses or infants less than one year of age to the California Genetic Disease Screening Program (GDSP) within 30
Genetic Disease Screening Program
days of initial diagnosis.
850 Marina Bay Parkway
Reportable neural tube defects (NTDs) are outlined by ICD-10-CM Codes Q00.0-Q01.9, Q05.0-Q05.9, Q07.0-Q07.03.
Room F-175, Mailstop 8200
Reportable chromosomal abnormalities are outlined by ICD-10-CM Codes Q90.0-Q99.9, excluding Q97.3, Q98.3, Q99.1, and Q99.2.
Submit a separate form for each individual specimen and for each fetus or infant in a multiple gestation.
Richmond, CA 94804
Report the simultaneous occurrence of a neural tube defect and a chromosomal abnormality for the same patient on one single form.
Print clearly in ink or type using UPPER CASE.
(510) 412-1560 (FAX)
Fill bubbles completely when marking.
INFORMATION ABOUT THE MOTHER
1. LAST NAME
2. FIRST NAME
3. MIDDLE INITIAL
4. MAIDEN NAME / AKA / OTHER NAMES USED FOR MOTHER
5. PRENATAL ACCESSION NUMBER (if mother participated in the California Prenatal Screening Program)
6. DATE OF BIRTH (MM/DD/YYYY)
7. APPROXIMATE AGE AT EDD (if date of birth is unknown)
8. SOCIAL SECURITY NUMBER
9. STREET ADDRESS (include apartment number)
10. CITY
11. STATE
12. ZIP CODE
13. MOTHER’S RACE / ETHNICITY (mark all that apply)
Asian Indian
Chinese
Hawaiian
Korean
Native American
White
Other (specify)
Black
Filipino
Hispanic
Laotian
Samoan
Unknown
Guamanian
Japanese
Middle Eastern
Vietnamese
Other Southeast Asian
Cambodian
INFORMATION ABOUT THE INFANT
14. LAST NAME
15. FIRST NAME
16. OTHER NAMES USED FOR INFANT (including father’s last name, if known)
17. DATE OF BIRTH (MM/DD/YYYY)
18. GENDER
19. FETUS LETTER CODE (A, B, C, etc.)
20. BIRTHWEGHT OF INFANT
21. IF DECEASED, DATE OF EXPIRATION (MM/DD/YYYY)
grams
INFORMATION ABOUT THE REPORTING SOURCE
22. LAST NAME (of person completing this form)
23. FIRST NAME (of person completing this form)
24. DATE FORM COMPLETED (MM/DD/YYYY)
25. TELEPHONE NUMBER (including extension)
ext
26. FACILITY TYPE
27. FACILITY NAME AND ADDRESS
Cytogenetic Laboratory
PDC (please provide PDC code)
Other (specify)
Hospital
MD
INFORMATION ABOUT THE PREGNANCY
28. LMP / LAST MENSTRUAL PERIOD (MM/DD/YYYY)
33. DATE OF PREGNANCY STATUS (MM/DD/YYYY)
32. PREGNANCY STATUS
Continuing Pregnancy
Elective Termination
29. EDD / ESTIMATED DATE OF DELIVERY (MM/DD/YYYY)
34. GESTATIONAL AGE AT TIME OF STATUS
Fetal Demise / SAB / Stillbirth / Missed Abortion
Pregnancy Completed with a Livebirth
weeks/days
Selective Reduction
30. # OF FETUSES IN PREGNANCY (including fetal demises)
Unknown / Lost to Follow-Up
35. METHOD USED TO DETERMINE GESTATIONAL AGE
Other (specify)
LMP
31. # OF FETUSES IN PREGNANCY WITH A BIRTH DEFECT
Physical Exam
Ultrasound
PRIVACY STATEMENT: The Information Practices Act of 1977 (Civil Code 1798 et. seq.) requires that the following details be provided when a form is used to obtain information from individuals. The data requested in this form are required by
the Genetic Disease Screening Program (GDSP) of the California Department of Public Health and are mandated by California Code of Regulations, Title 17, Section 6532. These data are used to provide information to subjects on the
prevention of birth defects, to determine the prevalence of neural tube defects and chromosomal abnormalities, and to monitor trends of occurrence. These data will also be used to determine the effectiveness of the California Expanded Alpha
Fetoprotein (AFP) Screening Program. It is mandatory that health professionals completing this form provide complete and accurate information. The records maintained by the GDSP are confidential, as defined in Civil Code 1798.34, and are
exempt from access by any individual, except licensed medical personnel designated by the subject. The information may also be used in special studies, as defined in Health and Safety Code 100330. The furnishing of such information to the
Department or its authorized representative or any other cooperating individual, agency, or organization in any such special study shall not subject any person, hospital, or other organization furnishing such information to any actions or
damages.
CDPH 4427 (11/2015)
Page 1 of 2
(Page 2 on reverse)
California Department of Public Health
Genetic Disease Screening Program
Please list the patient’s name in case of page separation:
INFORMATION ABOUT THE HOSPITAL
38. MOTHER’S MEDICAL RECORD NUMBER
36. NAME OF BIRTH HOSPITAL
39. INFANT’S MEDICAL RECORD NUMBER
37. TELEPHONE NUMBER OF BIRTH HOSPITAL
INFORMATION ABOUT THE PHYSICIAN
40. NAME AND ADDRESS OF MOTHER’S PHYSICIAN
42. NAME AND ADDRESS OF INFANT’S PHYSICIAN
41. TELEPHONE NUMBER OF MOTHER’S PHYSICIAN
43. TELEPHONE NUMBER OF INFANT’S PHYSICIAN
BIRTH DEFECT DIAGNOSIS – CHROMOSOMAL ABNORMALITIES
44. CYTOGENETIC DIAGNOSIS (ISCN Short Form) – Copy and paste or write diagnosis clearly using UPPER CASE below. Include Human Genome Build in nomenclature when applicable.
Do not report a) Heterochromatin Variants; b) Satellite / Stalk Variants of Chromosomes 13, 14, 15, 21, or 22; c) Inv(2)(p11;q13); d) Inv(9)(p11;q12 or q13) e) Familial Y Variants; f) Pseudomosaics;
g) Known Benign Variants; or h) Regions of Homozygosity
45. CYTOGENETIC ANALYSIS TYPE
46. SPECIMEN PREPARATION
50. CLINICAL SIGNIFICANCE
53. IS DIAGNOSIS PART OF A SYNDROME?
Karyotype
FISH
Cultured
Known Clinical Significance
Yes (specify)
Microarray
Direct
Unknown Clinical Significance
No
Unknown
47. CYTOGENETIC LABORATORY SPECIMEN NUMBER
51. INHERITANCE OF REARRANGEMENTS
Paternal
De Novo
54. SAMPLING DATE (MM/DD/YYYY)
Maternal
Unknown
48. NAME OF CYTOGENETIC LABORATORY
52. REASON FOR SAMPLE
Confirmation of Prenatal Diagnosis
55. GESTATIONAL AGE (GA)
56. METHOD USED TO
Congenital Anomalies
49. CYTOGENETIC SPECIMEN TYPE
AT TIME OF SAMPLING
DETERMINE GA
Dysmorphic Features
LMP
Abortus Specimen
Liveborn Blood
Liveborn Tissue
Maternal Age
weeks/
Physical Exam
Amniotic Fluid
Liveborn Bone Marrow
Umbilical Blood (PUBS)
days
Other (specify)
Ultrasound
Chorionic Villus (CVS)
Stillborn Tissue / Blood
Liveborn Cord Blood
BIRTH DEFECT DIAGNOSIS – NEURAL TUBE DEFECTS
57. NEURAL TUBE DEFECT DIAGNOSIS
61. ULTRASOUND INFORMATION:
63. AF-AFP LEVEL (in M.o.M.)
Spina Bifida includes Lipomeningocele, Meningocele,
NAME AND ADDRESS OF FACILITY OR PDC CODE
.
Meningomyelocele, and Myelomeningocele
Acrania
64. AF-AChE RESULT
Anencephaly
Positive
Craniorachischisis
GESTATIONAL AGE AT TIME OF PROCEDURE
Negative
Encephalocele
weeks/days
Not Performed
Exencephaly
65. IF POSTNATALLY DIAGNOSED, WHEN WAS NTD DIAGNOSED?
Iniencephaly
DATE OF PROCEDURE (MM/DD/YYYY)
At Time of Livebirth
Meckel Gruber
At Time of Stillbirth
Rachischisis
During Physical Examination
Spina Bifida / Myelomeningocele - Open
DID ULTRASOUND PROCEDURE DETECT NTD?
Other (specify)
Spina Bifida / Myelomeningocele - Closed
Yes
Other (specify)
No
66. DATE OF POSTNATAL DIAGNOSIS (MM/DD/YYYY)
62. AMNIOCENTESIS INFORMATION:
NAME AND ADDRESS OF FACILITY OR PDC CODE
58. IS HYDROCEPHALY PRESENT?
67. WAS THE FETAL ABNORMALITY POSTNATALLY CONFIRMED?
Yes
No
Yes
No
Unknown
GESTATIONAL AGE AT TIME OF PROCEDURE
Pending
59. IS NTD PART OF A SYNDROME?
weeks/days
Yes (specify)
68. SOURCE(S) OF CONFIRMATION (mark all that apply)
No
DATE OF PROCEDURE (MM/DD/YYYY)
Autopsy / Pathology Report
Unknown
Clinician Notes
60. ARE OTHER ABNORMALITIES PRESENT?
Delivery Room Report
DID AMNIOCENTESIS PROCEDURE DETECT NTD?
Outcome of Pregnancy
Yes (specify)
No
Yes
Ultrasound Report
Unknown
No
Other (specify)
CDPH 4427 (11/2015)
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