DELAWARE BIRTH DEFECTS REGISTRY REGISTRY REPORTING FORM The registry will collect information on all births after viability and any child under the age of five (5) who is a resident of the state of Delaware or whose parent is a resident of Delaware, and who is diagnosed at any time prior to age five (5) as having a birth defect. CHILD INFORMATION - PLEASE PRINT Child’s Name: _________________________________________________________________________________ Last First MI Date of Birth: / / MM DD YYYY Hospital of Birth: (or home or other)__________________________________________________________ Sex: _____M _____ F ____Undetermined Child’s Address: ______________________________________________________________________________ City: _____________________ State: _____ Zip:________ Phone: (_____)_________________________ Birth Weight: _______ g APGAR: 1 min ____ 5 min ____ 10 min ____ Gestational Age _______ wks. Still Birth > ____ 20 weeks ____ Spontaneous AB ____ Induced AB ____ Neonatal Death (Birth to 28 days) ____ Post-natal death 29-365days Race – check all that apply: Ethnicity: ___ White Hispanic: ___Yes ___No ___ Black or African American ___ American Indian or Alaska Native If Yes, please specify: ___ Asian Indian ___ Mexican, Mexican American, ___ Chinese Chicano ___ Filipino ___ Puerto Rican ___ Japanese ___ Cuban ___ Korean ___ Other:________________________ ___ Vietnamese ___ Other Asian: _____________ ___ Native Hawaiian ___ Guamanian or Chamorro ___ Samoan ___ Other Pacific Islander: ________________________ ___ Other: _________________ Parent/Legal Guardian(name): __________________________________________________________________ Last First MI Address (if different than child): ____________________________________________________________ City: _______________________________ State: ________ Zip: ______ Primary Care Physician: _______________________________________City: __________________________ Major Diagnosis: _______________________________ ICD-9: ________(Use separate sheet for other diagnoses) Cytogenic Studies performed: ___Yes ___No Autopsy performed: ___Yes ___No Comments: Comments: MOTHER INFORMATION - PLEASE PRINT Summary of All Pregnancies During Pregnancy Teratogenic Exposures ___Y ___N Total Previous Preg ______ Weight gained (lbs) _____ Details:________________________ Live Births ______ Folid Acid taken ___Y ___N ________________________________ Still Birth >20 wks ______ Vitamins Taken ___Y ___N ________________________________ Spontaneous Abortions ______ Other Medications/ Avg # alcoholic drinks/wk ______ Induced Abortions ______ Drugs Taken ___Y ___N Cigarette usage during Neonatal Deaths ______ Details __________________ pregnancy/day __________________ Post Neonatal Deaths ______ __________________________ Use 0=none for both questions DIAGNOSTICIAN INFORMATION - PLEASE PRINT Name:___________________________________________________________________________________________ Last First MI Title Address: _______________________________________________________________________________________ City: ____________________________ State: ________ Zip: _________ Phone Number: (____)__________________ Fax: (____)___________________ Licensure Type: _________ Specialty: ______________________________________________ Subspecialty: ________________________ Facility where diagnosis was made: _____Private Practice (name): ______________________________ _____Specialty Clinic (name): ______________________________ _____Practice (name): ______________________________________ _____Hospital (name): ______________________________________ _____Other (name of facility): _____________________________ Diagnostician Signature: ____________________________________ Reporting Date: __________________ Directions on Page 2 Doc. No. 35-05-02/20/06/02/32 SUBMIT TO: Delaware Division of Public Health, Birth Defects Registry Attention: Newborn Screening Program 417 Federal Street, Dover, DE 19901 Phone: 1-800-262-3030 or (302) 741-2990 Fax: (302) 741-8576 RETAIN A COPY FOR FILE Instructions for Completing the Delaware Birth Defects Registry Reporting Form PATIENT INFORMATION Child’s name: last name, first name, middle initial Date of Birth: child’s date of birth, month/day/year Hospital of Birth: name of hospital where child was born, or home address, or other specifics Sex: check male, female or undetermined Child’s address: street address, city, state, and zip code Phone number: area code and phone number Birth Weight: provide weight in grams at birth APGAR: provide score for 1 and 5 minutes or 5 and 10 minutes Gestation: write gestational week baby was born Still Birth: only check one of these boxes if it is applicable Race: check all that apply; fill in “other” if needed Ethnicity: check Hispanic Yes, or No; If Hispanic Yes, check the origin listed, or fill in “other” if needed Parent or legal guardian: last name, first name Parent or legal guardian address: (if different than child’s) Primary Care Physician: name and city of practice for PCP Diagnosis: brief description and ICD-9 code. Cytogenetic Studies Performed: check appropriate box and add comments if applicable Autopsy Performed: check appropriate box and add comments if applicable Summary of All Pregnancies: please fill in all 7 lines. Lines 2-7 include this birth also During Pregnancy: circle yes or no for each item and fill in names of medications/drugs on lines Teratogenic Exposures: leave box empty if there were no teratogenic exposures. Fill in names of teratogens if exposure occurred in home, workplace or other DIAGNOSTICIAN INFORMATION Name: name of diagnostician: last name, first name, middle initial, title Address: street address, city, state, and zip code Phone number: area code and phone number Fax number: area code and phone number Licensure Type: type of licensure, if any, attained by diagnostician Highest Degree and Year Attained: highest degree and year attained by diagnostician Specialty: diagnostician area of specialty Subspecialty: diagnostician area of subspecialty, if any Facility where diagnosis was made: check type of facility and fill in name of facility where diagnosis was made Diagnostician Signature: signature of the person/diagnostician who made the diagnosis Please make a copy of this Reporting Form for your records. Fax or mail form to address given. Thank you.