Initial Report Date:// ID#///

(mm/dd/ yyyy) (yr/county/mother/hh#)

Infant Information:

Last Name: / First Name:
DOB:// Time of Birth / Gender: Female Male / Birth Weight (in lbs)_ (4.4lbs = preterm)
Mother’s First Name: / Mother’s Last Name: / Mother’sDOB://
Address: / City: / Zip: / County:
Home Phone:-- / Work Phone: -- / Medicaid #: / SSN# --
Race/Ethnicity: / DeliveryHospital:
Emergency Contact Information:

Infant Provider Information:

Doctor’s/Clinic Name: / Phone: -- / Fax:--
Address: / City: / Zip:
Infant Vaccination Schedule Guide:
Series 1 / Engerix / Recombivax (Monovalent) / Pediarix®
(Combination) / Comvax®
(Combination)
HBIG / Within 12 hours of birth / Within 12 hours of birth (Monovalent) / Within 12 hours of birth (Monovalent)
1st Hep B dose / Within 12 hours of birth / Within 12 hours of birth (Monovalent) / Within 12 hours of birth (Monovalent)
2nd Hep B dose / Age 1 month / Age 2 months (Pediarix®) / Age 2 months (Comvax®)
3rd Hep B dose / Age 6 months / Age 4 months (Pediarix®) / Age 4 months (Comvax®)
4th Hep B dose / Age 6 months (Pediarix®) / Age 12-15 months (Comvax®)

HBIG and Hepatitis B Vaccine Record – Series 1:

Series 1 / Date / Dose / Time / Formulation / Manufacturer / Lot Number / Provider
(Doctor / Clinic)
HBIG / //
1st Hep B dose / //
2nd Hep B dose / // / NA
3rd Hep B dose / // / NA
4th Hep B dose / // / NA
Post Vaccine Serology Results – Series 1:(Must be performed 3 months after completing vaccine series)
Type of Test / Test Date / Result / Reporter (Lab) / Provider (Doctor/Clinic)
HBsAg / //
Anti-HBs / //

*If infant does not seroconvert repeat vaccine series and post vaccine serology testing, see page 2.

Comments:

*If Lost to Follow-up or Non Compliant, please obtain vaccination and/or PVS record history from:

Immtrac:Yes No If yes Immtrac #: Pediatric Health Care Provider:Yes No

Prior to submitting the Case Management Report to the regional perinatal hepatitis B prevention nurse coordinator, please ensure that all appropriate areas of the form are completed. The Case Management Report MUST be submitted within 15 days after the initial report date. All updates should be sent immediately to the regional perinatal hepatitis B prevention nurse coordinator. If the infant moves from your jurisdiction before completing all prevention activities, please complete the Case Management Transfer form, include the new address and submit to the regional perinatal hepatitis B prevention nurse coordinator

InfantDisposition:(refer to page 2 for closure and status codes)

DateClosed: // Reason Closed: Status:

.

Perinatal Hepatitis B Prevention Program

Infant Case Management Report

PO Box 149347/Mail Code 1939

Austin, TX 78714-9347

FAX: (512) 458-7787 PHONE: (512) 458-7447

ID#///

(yr/county/mother/hh#)

Hepatitis B Vaccine Record – Series 2: Complete Series 2 -if infant did not seroconvert AFTER SERIES 1

Series 2 / Date / Dose / Formulation / Manufacturer / Lot Number / Provider (Doctor / Clinic)
1st Hep B dose / //
2nd Hep B dose / //
3rd Hep B dose / //
Post Vaccine Serology Results – Series 2:(Must be performed 3 months after completing vaccine series)
Type of Test / Test Date / Result / Reporter (Lab) / Provider /Clinic
HBsAg / //
Anti-HBs / //

*If Lost to Follow-up or Non Compliant, please obtain vaccination and/or PVS record history from:

Immtrac:Yes No If yes Immtrac #: Pediatric Health Care Provider:Yes No

Prior to submitting the Case Management Report to the regional perinatal hepatitis B prevention nurse coordinator, please ensure that all appropriate areas of the form are completed. The Case Management Report MUST be submitted within 15 days after the initial report date. All updates should be sent immediately to the regional perinatal hepatitis B prevention nurse coordinator. If the infant moves from your jurisdiction before completing all prevention activities, please complete the Case Management Transfer Form, include the new address and submit to the regional perinatal hepatitis B prevention nurse coordinator.

Infant Disposition: (refer to chart below for closure and status codes)

DateClosed: // Reason Closed: Status:

Closure Codes / Explanation
1 / Completed Case Management
(received complete vaccine series and Post Vaccine Serology)
2 / Completed Service
(Screened or had previous documentation of testing)
3 / Death Of Client
4 / Ineligible
(Use if index case is not pregnant or is not HBsAg+)
5 / Lost to Follow-up
6 / Moved Out of State
7 / Moved Out of Country
8 / Noncompliant / Refused
9 / Never Located
10 / Transferred
11 / Houston / San Antonio
Status Codes / Explanation
1 / Immune
(Vaccinated)
2 / Immune
(Resolved Infection)
3 / Infected
(Carrier)
4 / Vaccinated not tested
5 / Discrepant Results
6 / Susceptible
7 / Non-responder
8 / Unknown

Texas Department of State Health Services Stock # EF11-10931

Communicable Disease ControlGroup Revised 04/2011