Free _PERINATAL HEPATITIS B SCREEN - Indiana

PERINATAL HEPATITIS B SCREEN
SF 45057 (R6/10-07) CLIA Certified Laboratory #15D0662599

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INDIANA STATE DEPARTMENT OF HEALTH LABORATORIES TH 550 W. 16 STREET, SUITE B INDIANAPOLIS, IN 46202-2203 (317) 921-5500

This questionnaire is authorized by IC 16-19-3-1 and 42 USC247(b). Although response is voluntary, cooperation is necessary for the study and control of the disease. This information is confidential pursuant to IC 16-41-8-1 and IC 16-39.

PATIENT INFORMATION
FOR ISDH USE ONLY Patient's Last Name First Middle ISDH Lab No. _____________ Patient's Address Date Received ____________ City DOB County Telephone ( ) State Zip Estimated Date of Confinement High Risk ________________ Date Specimen Collected

Race

Ethnicity

Sex

PATIENT HISTORY (complete only for prenatal patients) Refugee Yes No Specimen This Pregnancy First Second HBV Immunization Yes No Trimester diagnosed: First Second Third

ISDH Lab. No.__________ Other ______________ Date(s) ________________ Yes Post-Delivery Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown (Previous Specimen) No Unknown

Diagnosed acute HBV infection during current pregnancy?...........................................

Past diagnosed HBV infection?.............................................................................. Current symptoms of hepatitis?................................................................................ Past acute/chronic liver disease? ........................................................................... Past transfusion or hemodialysis?............................................................................ Past or current use of IV drugs?................................................................................. Past or current sexual contact with IV drug users? ..................................................... Past or current sexual contact with greater than 1 partner in the last 6 months?............... More than one episode of STD?.............................................................................. Past or current health care employment with exposure to blood/body fluids?.................... Past or current work in residential institutions for mentally handicapped persons?............... Past or current sexual/household contact with HBV patient/carrier? ...............................
Country of Origin: ______________________________________

CONTACT HISTORY (complete only for contacts of prenatal positive patients) Relationship to prenatal patient: Immunized infant born to prenatal positive mother Household/sexual contact (including other children) Name of prenatal patient: ____________________________________________________

For ISDH USE ONLY
LABORATORY RESULT
Doctor's Name __________________________________________________________________

Date:___________ Positive Positive Positive Negative Negative Negative

HbsAg (EIA) Anti-HBs (EIA)

Address _______________________________________________________________________

Anti-HBc (EIA) Comments

___________________________

City _______________________________________ State ______ ZIP code ________________

______________________________________ ______________________________________

County ____________________________________ Office Phone (______) _________________

Reporting Microbiologist

PERINATAL HEPATITIS B SCREENING PROGRAM

INTENDED USE The purpose of this program is to screen pregnant women in the state of Indiana for the hepatitis B virus. One serum sample should be collected from each patient as early as possible in the pregnancy for laboratory testing at the ISDH. Additional samples may be required if initial results are positive or if the patient is at high risk of infection. In addition, contacts of seropositive women will be screened.

SEROLOGICAL SPECIMEN COLLECTION 1. Collect 5-10 ml of blood in a serum-separator tube with a tight-fitting cap and label with patient name and collection date. Use writing implements that do not smear. 2. Complete this form on reverse side in ink, including 9-digit zip code, with each properly labeled specimen.

PACKING AND SHIPPING SPECIMENS 1. Use container 11C provided by the ISDH for shipping specimens. 2. Wrap the absorbent material, provided inside the inner mailing container, around the specimen tube to absorb shock and contain possible leakage. Insert wrapped specimen tube into inner mailing container and secure cap. Wrap completed request form around inner container and place in outer mailing container. Secure cap tightly. 3. Complete the pre-addressed label on outer mailing container with a return address and postage, and send via first class US mail. 4. Please use above packaging instructions to assure compliance with federal shipping regulations and to minimize breakage. Broken or leaking specimens present a biohazard and cannot be tested.