Free Confidential Birth Defects Registry Report, F-40054 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-40054 (12/03)

STATE OF WISCONSIN Bureau of Community Health Promotion

CONFIDENTIAL BIRTH DEFECTS REGISTRY REPORT
Completion of this form by physicians and pediatric specialty clinics is mandated under the provisions of sections 253.12(1) and 253.12 (2) of the Wisconsin Statutes. Completion of this form by hospitals is voluntary. Personally identifiable information collected on this form will only be used for matching and unduplication purposes. 1. Print firmly and neatly 2. Use pen only with dark ink 3. Print inside boxes 4. Fax/mail original form 5. Darken circles completely 6. Mark errors like this:

A. GENERAL INFORMATION
(1) Is this report a new report or a correction or addition to a previous report? (2) Has a Parental Consent Form been signed by a parent or guardian? O New O Yes O Correction O No

(3) Has a Referral Already Been Made to: Regional Children with Special Health Care Needs Center O Yes O No Local Public Health Department O Yes O No Local Birth to 3 Program O Yes O No Other (specify): _________________________________________________________________________________________________________

B. REPORTER
Today's Date (mm/dd/yyyy) Name, Title, Telephone and E-mail Address of Person Completing Form

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C. REPORTING SOURCE
Facility Name/Number, Address, City, State and Zip Code (stamp acceptable)

D. CHILD'S INFORMATION
Last Name Date of Birth (mm/dd/yyyy)

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First Name M.I. Medical Record Number Street Address

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City

State

Zip Code

Sex O Female O Male O Undesignated

Race (check all that apply) Ethnicity O American Indian or Native Alaskan O White O Hispanic or O Asian O Other________________ Latino O Black/African American O Unknown O Not Hispanic or O Hawaiian/Pacific Islander Latino Gestational Age Estimate Weeks:

List other names for child, if any

Birth Birthweight O Live O Grams O Pounds/Ounces O Stillbirth > 20 weeks ______________________ gestation

Is Birth O Single OTwin O Other Multiple______ O Unknown

Birth Order (if multiple) O First O Second O Other (specify):

Place of Birth: Hospital Name/Code, Street Address, City, State, Zip Code

E. CHILD'S PRIMARY CARE PROVIDER
Name of Primary Care Provider, and Facility Name

Area Code

Telephone Number

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F-40054 (12/03) Page 2

F. CHILD'S MOTHER
Last Name Date of Birth (mm/dd/yyyy)

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First Name M.I. Maiden Name

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City (at time of birth)

State

Zip Code

Race (check all that apply) O American Indian or Native Alaskan O White O Asian O Other __________________________ O Black/African American O Unknown O Hawaiian/Pacific Islander

Ethnicity O Hispanic or Latino O Not Hispanic or Latino

G. CHILD'S FATHER
Last Name Date of Birth (mm/dd/yyyy)

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First Name M.I. Race (check all that apply) O American Indian or Native Alaskan O White O Asian O Other __________________________ O Black/African American O Unknown O Hawaiian/Pacific Islander Ethnicity O Hispanic or Latino O Not Hispanic or Latino

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H. DIAGNOSTIC INFORMATION
Last Name of Physician Making Diagnosis Date of Diagnosis (mm/dd/yyyy)

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First Name M.I. License Number Specialty Area

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Area Code

Telephone Number

Condition(s) prenatally diagnosed? Is child deceased? O Yes O Yes O No O No O Unknown If child is deceased, date of death (mm/dd/yyyy)

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I.
Code

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Reportable Condition (first 25 letters/spaces)

WISCONSIN BIRTH DEFECTS REGISTRY REPORTABLE CONDITIONS

F-40054 (12/03) Page 3

INSTRUCTIONS
CONFIDENTIAL BIRTH DEFECTS REGISTRY REPORT
(1) This report form is to be used by physicians, pediatric specialty clinics and hospitals to report birth defects for children up to age two. The report is mandated under the provisions of sections 253.12(1) and 253.12(2) of the Wisconsin Statutes. The information is submitted to the Wisconsin Department of Health Services, Bureau of Community Health Promotion, Children with Special Health Care Needs Program. Please fill out as much information as possible. Leave items blank if you don't have the information. Do not write "N/A" or similar in the spaces. This report can be submitted via the Internet. Refer to the website at: https://wbdr.han.wisc.edu for electronic forms and instructions. If completing the report on paper, fax to Elizabeth Oftedahl, CSHCN Epidemiologist, Bureau of Community Health Promotion at 608/267-3824. If sending by U.S. Postal Service mail, her mailing address is 1 W. Wilson Street, P.O. Box 2659, Madison, WI 53701-2659. Be sure to provide a name, title, telephone number and e-mail address for the person filling out the report so that person can be contacted if there are any questions. Use the list at the end of this page for section I of the report. If the reportable condition is longer than 25 letters and spaces, put in the proper code number and the first 25 letters and spaces of the reportable condition. Be sure the parent/guardian has signed a parental consent form (provided and maintained by you or your facility) before submitting the report. If the parent/guardian refuses to sign a consent form, you are still required to report. However, do not provide a name or address for the child or for the child's parents. Do provide date of birth, medical record number (if available), sex, race, ethnicity, birth outcome, birthweight, gestational age estimate, plurality and, if multiple, birth order information. Contact Elizabeth Oftedahl at 608-261-9304 if you have questions or comments. She can also be reached via e-mail at [email protected]

(2) (3) (4) (5) (6) (7)

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Wisconsin Birth Defects Registry Reportable Conditions
CARDIOVASCULAR
100 101 102 103 104 105 106 107 108 109 110 150 151 152 153 154 155 156 Atrial Septal Defect Atrioventricular Canal/Endocardial Cushion Defect Cardiac Arrhythmia (Congenital) Coarctation of the Aorta Hypoplastic Left Heart Tetralogy of Fallot Total Anomalous Pulmonary Venous Return Transposition of the Great Vessels Truncus Arteriosus Valvular Heart Disease (Congenital) Ventricular Septal Defect

HEMATOLOGIC
400 Hemophilia 401 Hereditary Spherocytosis 402 Von Willebrand Disease

MUSCULOSKELETAL
450 451 452 453 454 455 456 457 458 459 460 500 501 502 503 504 505 506 507 508 550 551 552 553 554 Achondroplasia Amniotic Bands Arthrogryposis Multiplex Congenita Bone Dysplasia/Dwarfism, Other (not Anchondroplasia) Clubfoot (Congenital) Hip Dislocation (Congenital)/Developmental Dysplasia of Hip (Congenital) Hemivertebra Osteogenesis Imperfecta Scoliosis (Infantile) and/or Kyphosis Reduction Deformity, Arm or Hand Reduction Deformity, Leg or Foot

CHROMOSOMAL
Down Syndrome Klinefelter Syndrome Trisomy 13 Trisomy 18 Turner Syndrome Velocardiofacial Syndrome (22q Deletion Syndrome) Other Chromosomal Anomaly (not Down Syndrome, Klinefelter Syndrome, Trisomy 13, Trisomy 18, Turner Syndrome or Velocardiofacial Syndrome)

NEUROLOGIC
Anencephaly Encephalocele Holoprosencephaly Hydranencephaly Hydrocephalus (Congenital or Early) Microcephaly (Congenital or Early) Porencephaly Spina Bifida Spinal Muscular Atrophy (Infantile)

ENDOCRINE
200 Hypothyroidism (Congenital)

EYE
250 251 252 253 300 301 302 303 304 305 306 307 350 351 352 353 354 355 356 357 358 359 360 361 Cataract (Congenital or Early) Coloboma Glaucoma (Congenital) Microphthalmia/Anophthalmia

OROFACIAL
Choanal Atresia Cleft Lip with or without Cleft Palate Cleft Palate Craniosynostosis Microtia/Anotia

GASTROINTESTINAL/ABDOMINAL
Biliary Atresia Gastroschisis Hirschsprung Disease Omphalocele Pyloric Stenosis Rectal/Colonic Atresia/Stenosis Small Bowel Atresia/Stenosis Tracheo-Esophageal Fistula/Esophageal Atresia

PULMONARY
600 Cystic Fibrosis 601 Diaphragmatic Hernia

SYNDROMES/ASSOCIATIONS
650 651 652 653 654 655 656 657 658 659 660 661 662 663 Angelman Syndrome Beckwith-Wiedemann Syndrome CHARGE Association De Lange Syndrome (Cornelia De Lange Syndrome) Marfan Syndrome Noonan Syndrome Oculoauriculovertebral Association (including Goldenhar Association and Hemifacial Microsomia) Prader-Willi Syndrome Robin Malformation Sequence (Pierre Robin Sequence) Smith-Lemli-Opitz Syndrome Sotos Syndrome Stickler Syndrome VATER Association Williams Syndrome

GENITOURINARY
Ambiguous Genitalia Epispadias Exstrophy of the Bladder/Cloaca Hypospadias Multicystic and/or Dysplastic Kidney Obstructive Urinary Tract Defect (not Posterior Valves; not Urethral Stenosis/Atresia) Polycystic Kidney Disease, Autosomal Dominant Form Polycystic Kidney Disease, Autosomal Recessive Form Polycystic Kidney Disease, Uncertain Form Posterior Urethral Valves Renal Agenesis/Hypoplasia Urethral Stenosis/Atresia