Form DOH348-030 "Perinatal Hepatitis B Confidential Case Report - Mother/Infant" - Washington

What Is Form DOH348-030?

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

Form Details:

  • Released on November 1, 2001;
  • The latest edition provided by the Washington State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH348-030 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

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Download Form DOH348-030 "Perinatal Hepatitis B Confidential Case Report - Mother/Infant" - Washington

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Washington State Immunization Program
P.O. Box 47843 Olympia, WA 98504-7843
PERINATAL HEPATITIS B CONFIDENTIAL CASE REPORT - MOTHER/INFANT
Please complete all sections of this form. See detailed instructions on back.
Section I: Mother's Information
MOTHER'S NAME
LAST
FIRST
MAIDEN
MOTHER'S DATE OF BIRTH
ADDRESS STREET
MOTHER'S HOME TELEPHONE
(
)
CITY
STATE
ZIP
COUNTY
WORK OR MESSAGE TELEPHONE
(
)
MOTHER'S RACE
White
Black
Asian
American Indian
Hispanic
Unknown
Other (specify)
EDC (DATE)
DELIVERY HOSPITAL
MOTHER'S HEALTH CARE PROVIDER NAME (OPTIONAL)
PROVIDER'S TELEPHONE (OPTIONAL)
(
)
PROVIDER'S STREET ADDRESS (OPTIONAL)
CITY
STATE
ZIP
COUNTY
DATE OF POSITIVE HBSAG TEST
PAYMENT SOURCE
ADMINISTERED BY
Health Dept.
Hospital
Insurance
Medicaid
None
Private Provider
Unknown
Other
Unknown
Other (specify)
Section II: Infant's Information
INFANT'S NAME
LAST
FIRST
MIDDLE INITIAL
SEX
DATE OF BIRTH
Female
Male
Unknown
INFANT'S HEALTH CARE PROVIDER NAME (OPTIONAL)
PROVIDER'S TELEPHONE (OPTIONAL)
(
)
PROVIDER'S STREET ADDRESS (OPTIONAL)
CITY
STATE
ZIP
COUNTY
Vaccine
Date
Vaccine Brand
Administered by
Payment Source
Health Dept.
Unknown
Insurance
Unknown
HBIG
Hospital
Other
Medicaid
None
Private Provider
Other (specify)
Recombivax
Health Dept.
Unknown
Insurance
Unknown
Vaccine Dose 1
Engerix
Hospital
Other
Medicaid
None
Unknown
Private Provider
Other (specify)
Recombivax
Health Dept.
Unknown
Insurance
Unknown
Vaccine Dose 2
Engerix
Hospital
Other
Medicaid
None
Unknown
Private Provider
Other (specify)
Recombivax
Health Dept.
Unknown
Insurance
Unknown
Vaccine Dose 3
Engerix
Hospital
Other
Medicaid
None
Unknown
Private Provider
Other (specify)
Section III: Follow Up Serology (3-9 Months After Dose 3)
Test
Date
Results
Administered by
Payment Source
Positive
Health Dept.
Unknown
Insurance
Unknown
HBsAg
Negative
Hospital
Other
Medicaid
None
Unk/Untested
Private Provider
Other (specify)
Positive
Health Dept.
Unknown
Insurance
Unknown
Anti-HBs
Negative
Hospital
Other
Medicaid
None
Unk/Untested
Private Provider
Other (specify)
Section IV
Moved
Can't Locate
Refuses Follow up
Case Closed
False Positive
Pregnancy Ended
Other (specify)
Section V
MOTHER'S ID
CHILD'S ID
REPORT DATE
REPORTED BY
PHONE
COUNTY
NAME
DOH 348-030 FRONT ( 11/01)
Washington State Immunization Program
P.O. Box 47843 Olympia, WA 98504-7843
PERINATAL HEPATITIS B CONFIDENTIAL CASE REPORT - MOTHER/INFANT
Please complete all sections of this form. See detailed instructions on back.
Section I: Mother's Information
MOTHER'S NAME
LAST
FIRST
MAIDEN
MOTHER'S DATE OF BIRTH
ADDRESS STREET
MOTHER'S HOME TELEPHONE
(
)
CITY
STATE
ZIP
COUNTY
WORK OR MESSAGE TELEPHONE
(
)
MOTHER'S RACE
White
Black
Asian
American Indian
Hispanic
Unknown
Other (specify)
EDC (DATE)
DELIVERY HOSPITAL
MOTHER'S HEALTH CARE PROVIDER NAME (OPTIONAL)
PROVIDER'S TELEPHONE (OPTIONAL)
(
)
PROVIDER'S STREET ADDRESS (OPTIONAL)
CITY
STATE
ZIP
COUNTY
DATE OF POSITIVE HBSAG TEST
PAYMENT SOURCE
ADMINISTERED BY
Health Dept.
Hospital
Insurance
Medicaid
None
Private Provider
Unknown
Other
Unknown
Other (specify)
Section II: Infant's Information
INFANT'S NAME
LAST
FIRST
MIDDLE INITIAL
SEX
DATE OF BIRTH
Female
Male
Unknown
INFANT'S HEALTH CARE PROVIDER NAME (OPTIONAL)
PROVIDER'S TELEPHONE (OPTIONAL)
(
)
PROVIDER'S STREET ADDRESS (OPTIONAL)
CITY
STATE
ZIP
COUNTY
Vaccine
Date
Vaccine Brand
Administered by
Payment Source
Health Dept.
Unknown
Insurance
Unknown
HBIG
Hospital
Other
Medicaid
None
Private Provider
Other (specify)
Recombivax
Health Dept.
Unknown
Insurance
Unknown
Vaccine Dose 1
Engerix
Hospital
Other
Medicaid
None
Unknown
Private Provider
Other (specify)
Recombivax
Health Dept.
Unknown
Insurance
Unknown
Vaccine Dose 2
Engerix
Hospital
Other
Medicaid
None
Unknown
Private Provider
Other (specify)
Recombivax
Health Dept.
Unknown
Insurance
Unknown
Vaccine Dose 3
Engerix
Hospital
Other
Medicaid
None
Unknown
Private Provider
Other (specify)
Section III: Follow Up Serology (3-9 Months After Dose 3)
Test
Date
Results
Administered by
Payment Source
Positive
Health Dept.
Unknown
Insurance
Unknown
HBsAg
Negative
Hospital
Other
Medicaid
None
Unk/Untested
Private Provider
Other (specify)
Positive
Health Dept.
Unknown
Insurance
Unknown
Anti-HBs
Negative
Hospital
Other
Medicaid
None
Unk/Untested
Private Provider
Other (specify)
Section IV
Moved
Can't Locate
Refuses Follow up
Case Closed
False Positive
Pregnancy Ended
Other (specify)
Section V
MOTHER'S ID
CHILD'S ID
REPORT DATE
REPORTED BY
PHONE
COUNTY
NAME
DOH 348-030 FRONT ( 11/01)
INSTRUCTIONS FOR COMPLETING PERINATAL HEPATITIS B
CONFIDENTIAL CASE REPORT
MOTHER/INFANT
1.
Complete a case report form only for pregnant women who are HBsAg-positive during their
pregnancy and infants born to HBsAg-positive women.
2.
Complete the mother's information section as soon as the HBsAg-positive test result is
known. Keep the original case report for your files and send a copy of the case report to the
Immunization Program.
3.
Using the same case report as the mother's, complete the infant's information section,
including the information on HBIG and hepatitis B vaccine Dose #1 as soon as the infant is
born. Keep the original case report for your files and send a copy of the updated case report
to the Immunization Program.
4.
Complete the information on hepatitis B vaccine Dose #2 as soon as the information is
known. Keep the original case report for your files and send a copy of the updated case
report to the Immunization Program.
5.
Complete the information on hepatitis B vaccine Dose #3 as soon as the information is
known. Keep the original case report for your files and send a copy of the updated case
report to the Immunization Program.
6.
Complete the follow-up serology information as soon as the results are known. Keep the
completed original case report for your files and send a copy of the completed case report to
the Immunization Program.
One form should be completed for one mother and her infant with each pregnancy.
Summary:
The forms should be completed and copies sent to the Immunization Program at the
following times:
1.
After HBsAg-positive test on mother
2.
After birth of infant and vaccination with HBIG and Dose #1
3.
After vaccination with Dose #2
4.
After vaccination with Dose #3
5.
After follow-up serology
6.
After mother/infant case is closed
Immunization Program
PO Box 47843
Olympia, WA 98504-7843
(360) 236-3565
DOH 348-030 BACK (11/01)
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