Department of Public Health
Bureau of Infectious Disease
Laboratory Sciences.
Recieved in survellance:
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Hepatitis B Infected Pregnant Woman Reporting Form Confidential Case Report
First Name:
Middle Name:
Last Name:
Date Of Birth:(DD/MM/YEAR)
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Estimated Delivery Date:(DD/MM/YEAR)
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Aware of HepB+ status?
Yes
/
No
/
Unk
Address:
City:
State:
Zip:
Phone Number:
(
)
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-
Type of Insurance
Private
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Medicaid
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Medicare
Uninsured
Unknown
Race:
American
Asian
Black/Africa Ame.
Hispanic:
Yes
/
No
/
Unk
Native Hawaiian/Pacific Islander
White
Unk
Others
Country of Birth:
Primary Language:
Check If Interpreter is Needed:
LABORATORY INFORMATION
Laboratory Results: Check off below any POSITIVE labs and attach positive Hep B lab results
HBsAg (Hep B surface antigen)
HBeAg (Hep Be antigen)
IgM anti-HBc (IgM antibody to Hep B core antigen)
HBV DNA (Hep B virus DNA)
CLINICAL INFORMATION
OB Provider First Name:
OB Provider Last Name:
Provider Type:
MD/DO
Expected Delivery Facility:
Provider Type:
CNM/NP
Reporting Health Care Facility:
Provider Type:
PA
Address:
City:
State:
Zip:
Contact Person at Reporting Facility:
Direct Phone:
(
)
-
*
Date Form Completed:
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Positive Labs Attached