New Jersey Department of Health

Vaccine Preventable Disease Program

P. O. Box 369, Trenton, NJ 08625-0369

CONFIDENTIAL PERINATAL HEPATITIS-B CASE AND CONTACT REPORT

Instructions: Please complete all sections of this form. Print or type all information. Insert "Month/Day/Year" in all fields requiring a date. Questions can be addressed to the New Jersey Department of Health, Vaccine Preventable Disease Program at 609‑826‑4860.

Review the instructions for completion of the form and distribution of copies.

Name of Agency Making Report

Report Date (MM/DD/YY)
/	/
Name of Contact Person

Telephone Number

( )
SECTION I: DATA ON PRENATAL WOMAN
Name - Last First MI

County

CDRSS Case No.
Street Address

Apt. No.

Home Telephone Number

( )
City

State

Zip Code

Emergency Telephone Number

( )
Date of Birth (MM/DD/YY)	Age in Years	Ethnicity/Race (Check Only One)

1American Indian/Alaskan Native	3Black	5White	7Unknown

2Asian/Pacific Islander	4Hispanic	6Other (Specify) __________
/	/
Receiving/Received Prenatal Care

Yes No	Date of HBsAg(+) Test (MM/DD/YY)	EDC (MM/DD/YY)
/	/
/	/
Name of Hospital/Delivery Site

Telephone Number

( )
Address

Name of Prenatal Provider

Telephone Number

( )
Name of Pediatric Provider

Telephone Number

( )
SECTION II: DATA ON CONTACT(S)
Name of Local Health Department or Other Case Management Agency

Report Date (MM/DD/YY)
/	/
Name of Contact Person

Telephone Number

( )
Name of Contact

(Last Name, First Name)

Telephone Number	Relation-ship	Date of Birth	Sex	Serologic Screening	Immunization Dates
Done?

Y/N	Date Tested	Test Type	Result

(+/-)	HB #1	HB #2	HB #3	HBIG	Outcome Code *
NOTE: If more contacts are identified, attach an additional sheet to this report.
SECTION III: DATA ON NEWBORN
Outcome of Pregnancy

a. Number of Live Infants ______	b. Pregnancy Terminated: Yes No	Infant NJ Immunization Registry Number

Infant Name - Last First MI

Date of Birth (MM/DD/YY)
/	/
Sex

Male Female	Ethnicity/Race (Check Only One)

1American Indian/Alaskan Native	3Black	5White	7Unknown

2Asian/Pacific Islander	4Hispanic	6Other (Specify) ________
Date Vaccinated (MM/DD/YY)	Outcome Code *	Serology at 9 - 18 Months of Age

Serology Performed? Yes No

Lab Test	Date Performed (MM/DD/YY)	Result
HBIG
HB #1
HBsAg	/	/	Pos. Neg. Unk.
HB #2
Anti-HBs	/	/	Pos. Neg. Unk.
(Anti-HBs > 10 MIU/mL is positive result = immunity)
HB #3
Serology Performed? Yes No

Lab Test	Date Performed (MM/DD/YY)	Result
HB #4
HB #5
HBsAg	/	/	Pos. Neg. Unk.
HB #6
Anti-HBs	/	/	Pos. Neg. Unk.
IMM-20

JUL 12	*See Outcome Codes listed on Instruction page.

IMM-20, Confidential Perinatal Hepatitis B Case and Contact report

IMM-20, perinatal, hepatitis B, case and contact report, immunization, vaccine preventable disease program, VPDP,

ewhite

2006-04-25

NJDOH