New Jersey Department of Health

Vaccine Preventable Diseases Program

HEPATITIS B CASE REPORT

Instructions to Health Care Provider:

Hepatitis B, a communicable disease, is reportable to the New Jersey Department of Health under the New Jersey Administrative Code (NJAC) 8:57. Please note that the Health Insurance Portability and Accountability Act (HIPAA) expressly permits disclosures without individual authorization to public health authorities authorized by law to receive information for the purpose of preventing or controlling communicable disease.

Given the complexity of the hepatitis B disease case definition and the various serologic laboratory results, additional information is needed by public health officials to determine the patient’s case status. Additionally, the pregnancy status must be obtained for any HBsAg positive female age 15 to 45 years.

Your assistance is needed to determine the case status of the following patient. Please complete and return this form to the sender.

Demographics

CASE ID:
Name: Last:	First:	Middle:
Address:	Apt.:
City:	State:	Zip Code:
County:	Phone:	( _ _ _ ) _ _ _ - _ _ _ _
RACE (check all that apply):
American Indian or Alaska Native Black or African American White Asian Native Hawaiian or Pacific Islander
Other, specify:
ETHNICITY (check all that apply):
Hispanic Non-Hispanic Other/Unknown
SEX:
Male Female Unknown
BIRTHDATE:	_ _ / _ _ / _ _ _ _	PLACE OF BIRTH:	USA Other:
Hepatitis B Vaccination History? Yes No Unknown NJIIS ID (if applicable):
Dose 1:	_ _ / _ _ / _ _ _ _	Dose 2:	_ _ / _ _ / _ _ _ _	Dose 3:	_ _ / _ _ / _ _ _ _
For Females 15-45 Years of Age: PREGNANT? Yes No Unknown
If YES, Estimated Delivery Date:	_ _ / _ _ / _ _ _ _	Intended Delivery Site (if known):
Clinical and Diagnostic Data
SYMPTOMS (check all that apply):
Asymptomatic
Abdominal pain/cramps	Malaise	Nausea	Vomiting	Arthralgia	Fever	Clay-colored stool
Liver abnormalities	Cirrhosis	Anorexia	Dark urine	Loss of appetite	Rash
Elevated liver enzymes*	Jaundice	Other, specify:
REASON FOR TESTING (check all that apply): *
Screening of asymptomatic patient with no risk factors (i.e., patient request)
Screening of asymptomatic patient with reported risk factors
Prenatal screening	Year of birth (1945-1965)
Follow-up testing for previous marker of viral hepatitis	Symptoms of acute hepatitis
Evaluation of elevated liver enzymes	Unknown
Evidence of chronic hepatitis or liver disease	Blood/organ donor screening
Other, specify:
* Please attach copies of all relevant testing done including serology, liver enzymes and DNA.
Clinical and Diagnostic Data, continued
CLINICAL DIAGNOSIS:
Chronic hepatitis B	Acute hepatitis B	Perinatal hepatitis B infection
Acute hepatitis A	Hepatitis C infection	Other, specify:
Diagnosis Date:	_ _ / _ _ / _ _ _ _
Hospitalized for hepatitis? Yes No Unknown Died? Yes No Unknown
Was the patient aware they had hepatitis prior to lab testing? Yes No Unknown
risk factors
In the 6 weeks – 6 months prior to onset of symptoms, did the person (check all that apply):
Have contact with a confirmed or suspected hepatitis case
Foreign born in areas where hepatitis is endemic (where: ____________________)
Unprotected sex	Acupuncture	Injection drug user	Blood transfusion/recipient of blood products
Perinatal exposure	Dental procedure	Recent hepatitis B vaccination	Hemodialysis patient
Hospitalization	Tattoo/Piercing	Injections/infusions	Travel to high risk area
Occupational exposure	Organ donor/recipient	Previous/present incarceration	MSM
Use of finger stick devise/phlebotomy in home/other setting	No vaccination
Healthcare procedure (specify: ____________________)
education
Was the patient informed of diagnosis? Yes No
Have patient and/or family member been counseled on mode of transmission and precautions regarding hepatitis B? Yes No
contacts

(Use additional space at the bottom if necessary)
Name	Address	Telephone Number	Nature of Contact
Household	Casual

Sexual	Other
Household	Casual

Sexual	Other
Household	Casual

Sexual	Other
Household	Casual

Sexual	Other
Comments:

HEPATITIS B CASE REPORT

(Continued)

CDS-37 (formerly CDS-L2)

AUG 14	Page 2 of 2 Pages.

AUG 14	Page 1 of 2 Pages.

CDS-37, Hepatitis B Case Report

CDS-37, Hepatitis B, communicable disease service, Hep B, case report, cds-l2

EWhite

2014-08-18

NJDOH