Form EPID399 "Perinatal Hepatitis B Prevention Form for Infants" - Kentucky

What Is Form EPID399?

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

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Kentucky Department for Public 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 EPID399 by clicking the link below or browse more documents and templates provided by the Kentucky Department for Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form EPID399 "Perinatal Hepatitis B Prevention Form for Infants" - Kentucky

Download PDF

Fill PDF online

Rate (4.6 / 5) 25 votes
PERINATAL HEPATITIS B PREVENTION FORM FOR INFANTS
_______________________________________________
___________________
___________________
Full name of patient
Date of birth
Time of birth
_______________________________________________
___________________
___________________
Full name(s) of parent(s)
_______________________________________________
Mother’s date of birth
County of residence
Weight at vaccination
_______________________________________________
___________________
___________________
Patient’s address
Obstetrician’s name
Pediatrician’s name
_______________________________________________
___________________
____________________
City
State
Zip
Maternal Insurance Type
Infant Insurance Type
_____________________________________________
Phone Number
Biological
Site of
Manufacturer &
VIS Pub.
Date
Time
Dosage
RN Signature
Administered
Injection
Lot Number
Date
Hepatitis B
0.5 mL
Vaccine
HBIG
0.5 mL
If vaccine not given please specify reason: _____________________________________________________________________
Parent/Guardian signature for infant to receive hepatitis B (HepB) vaccine_______________________________________________
HBsAg testing
Yes (
)
Pending (
) *see below
Mother’s HBsAg Status:
Positive (
)
Negative (
)
________________________
Date of Mother’s lab work
***Notify the Infection Preventionist in your facility if the mother is HBsAg-positive***
*Pending ( ) A pending HBsAg is acceptable only if blood has been drawn and sent to a laboratory.
Attempt to obtain a verbal report of result from laboratory before the infant is discharged. If the HBsAg result is pending,
______________________________ (name) at _______________________ (phone number) is responsible for confirming the laboratory
results and telephoning the local health department if the mother is HBsAg-positive. If the mother did not have HBsAg testing during
prenatal care or if results are not available, please collect blood for HBsAg testing immediately after admission for delivery and
review results within 12 hours of birth. Telephone HBsAg-positive results to the local health department immediately.
Date /time of LHD notification__________________ Signature___________________________________________
Infants born to HBsAg-positive mothers must receive 0.5 mL monovalent Hepatitis B vaccine and 0.5 mL HBIG within 12 hours
of birth. If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine for infants weighing ≥2,000 grams,
and HepB vaccine plus HBIG for infants weighing <2,000 grams. Determine mother’s HBsAg status as soon as possible and, if she is
HBsAg-positive, administer HBIG for infants weighing ≥2,000 grams (no later than age 1 week).
_______________________________________________
(
)______________________
Name of Hospital or Other Institution
Telephone Number
Appropriate screening of pregnant women is an important step in the strategy to prevent perinatal hepatitis B infection. To decrease the perinatal
transmission of hepatitis B, all pregnant women in Kentucky must be screened for hepatitis B surface antigen (HBsAg). State legislation mandating the
testing became effective July 15, 1998. Administrative regulation 902.KAR 2:020 requires all licensed health professionals and facilities to report
hepatitis B in a pregnant woman to the local or state health department. This form is required to be completed on all infants born to HBsAg-positive
mothers and those whose HBsAg status is pending or unknown to insure adequate follow-up of a reportable disease. It is suggested that the
form be completed on all births to confirm every pregnant woman’s status has been verified and the infant has been treated appropriately.
*A copy of this form must be sent to the LHD in the maternal county of residence, a copy given to the parent, a
copy maintained at the hospital and a copy sent to the physician (ob/gyn and pediatrician).
EPID 399 Revision 4/2020
PERINATAL HEPATITIS B PREVENTION FORM FOR INFANTS
_______________________________________________
___________________
___________________
Full name of patient
Date of birth
Time of birth
_______________________________________________
___________________
___________________
Full name(s) of parent(s)
_______________________________________________
Mother’s date of birth
County of residence
Weight at vaccination
_______________________________________________
___________________
___________________
Patient’s address
Obstetrician’s name
Pediatrician’s name
_______________________________________________
___________________
____________________
City
State
Zip
Maternal Insurance Type
Infant Insurance Type
_____________________________________________
Phone Number
Biological
Site of
Manufacturer &
VIS Pub.
Date
Time
Dosage
RN Signature
Administered
Injection
Lot Number
Date
Hepatitis B
0.5 mL
Vaccine
HBIG
0.5 mL
If vaccine not given please specify reason: _____________________________________________________________________
Parent/Guardian signature for infant to receive hepatitis B (HepB) vaccine_______________________________________________
HBsAg testing
Yes (
)
Pending (
) *see below
Mother’s HBsAg Status:
Positive (
)
Negative (
)
________________________
Date of Mother’s lab work
***Notify the Infection Preventionist in your facility if the mother is HBsAg-positive***
*Pending ( ) A pending HBsAg is acceptable only if blood has been drawn and sent to a laboratory.
Attempt to obtain a verbal report of result from laboratory before the infant is discharged. If the HBsAg result is pending,
______________________________ (name) at _______________________ (phone number) is responsible for confirming the laboratory
results and telephoning the local health department if the mother is HBsAg-positive. If the mother did not have HBsAg testing during
prenatal care or if results are not available, please collect blood for HBsAg testing immediately after admission for delivery and
review results within 12 hours of birth. Telephone HBsAg-positive results to the local health department immediately.
Date /time of LHD notification__________________ Signature___________________________________________
Infants born to HBsAg-positive mothers must receive 0.5 mL monovalent Hepatitis B vaccine and 0.5 mL HBIG within 12 hours
of birth. If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine for infants weighing ≥2,000 grams,
and HepB vaccine plus HBIG for infants weighing <2,000 grams. Determine mother’s HBsAg status as soon as possible and, if she is
HBsAg-positive, administer HBIG for infants weighing ≥2,000 grams (no later than age 1 week).
_______________________________________________
(
)______________________
Name of Hospital or Other Institution
Telephone Number
Appropriate screening of pregnant women is an important step in the strategy to prevent perinatal hepatitis B infection. To decrease the perinatal
transmission of hepatitis B, all pregnant women in Kentucky must be screened for hepatitis B surface antigen (HBsAg). State legislation mandating the
testing became effective July 15, 1998. Administrative regulation 902.KAR 2:020 requires all licensed health professionals and facilities to report
hepatitis B in a pregnant woman to the local or state health department. This form is required to be completed on all infants born to HBsAg-positive
mothers and those whose HBsAg status is pending or unknown to insure adequate follow-up of a reportable disease. It is suggested that the
form be completed on all births to confirm every pregnant woman’s status has been verified and the infant has been treated appropriately.
*A copy of this form must be sent to the LHD in the maternal county of residence, a copy given to the parent, a
copy maintained at the hospital and a copy sent to the physician (ob/gyn and pediatrician).
EPID 399 Revision 4/2020