Get Case Report Form

Filling out the Case Report Form online is a crucial step in documenting cases related to congenital syphilis. This guide provides clear, step-by-step instructions to help users accurately complete the form with confidence.

Follow the steps to successfully complete the Case Report Form.

1. Click the ‘Get Form’ button to access the form and open it in your chosen online editor.
2. Begin with Part I: Maternal Information. Enter the mother's name, Case ID number, and CalREDIE ID, ensuring that all personal details are accurate. Fill in the delivery hospital's name and the infant's CalREDIE ID.
3. Complete the reporting details by providing the report date, the reporting county, state, and any relevant information about the mother's residence, including her city, state, and zip code.
4. Provide the mother's date of birth and demographic information such as ethnicity and race. Use the options provided to indicate if this data is unknown.
5. Indicate the number of prenatal visits and dates associated with syphilis testing. Include results for non-treponemal tests, if applicable, and specify if there were any confirmatory test results.
6. Proceed to Part II: Infant Information. Fill in the infant's name, date of delivery, and vital status, and add any details regarding the infant's healthcare evaluations, including test results and treatments received.
7. In Part III: Congenital Syphilis Case Classification, classify the case as confirmed, probable, or not a case based on the provided criteria.
8. Once all sections are completed, review the information for accuracy. Finally, save your changes, then download, print, or share the completed form as needed.

Complete the Case Report Form online to ensure accurate documentation and reporting.