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Revised 05/09/2013Congenital Syphilis Case Investigation and Reporting Form
Instructions
Note: These instructions accompany the Congenital Syphilis Case Investigation and Reporting
Form, CDC 73.126,
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How to fill out congenital syphilis reporting form
How to fill out congenital syphilis reporting form
01
Obtain a copy of the congenital syphilis reporting form from your local health department or download it online.
02
Fill out the patient's demographic information, including name, date of birth, gender, and address.
03
Provide details of the syphilis infection, such as the date of diagnosis, stage of infection, and any known complications.
04
Include information about the mother, including prenatal care received, history of syphilis, and treatment received.
05
Indicate the treatment history of the patient, including medications prescribed and dates of administration.
06
Sign and date the form to certify its accuracy.
07
Submit the completed form to the appropriate authorities or follow the instructions provided for submission.
Who needs congenital syphilis reporting form?
01
Healthcare providers who diagnose or treat cases of congenital syphilis need to fill out the congenital syphilis reporting form. This includes doctors, nurses, midwives, laboratories, and other healthcare professionals who come in contact with patients affected by congenital syphilis.
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What is congenital syphilis reporting form?
The congenital syphilis reporting form is a standardized document used to report cases of congenital syphilis, which is an infection transmitted from mother to child during pregnancy.
Who is required to file congenital syphilis reporting form?
Healthcare providers, including physicians and hospitals, are required to file the congenital syphilis reporting form when they diagnose or treat a case of congenital syphilis.
How to fill out congenital syphilis reporting form?
To fill out the congenital syphilis reporting form, providers must complete all required sections including patient information, clinical details, maternal history, and relevant laboratory results.
What is the purpose of congenital syphilis reporting form?
The purpose of the congenital syphilis reporting form is to monitor the incidence of congenital syphilis, inform public health responses, and facilitate the prevention and control of syphilis in pregnant women.
What information must be reported on congenital syphilis reporting form?
Information required on the congenital syphilis reporting form includes the patient's demographics, clinical presentation, maternal syphilis history, treatment received, and laboratory test results.
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