Fill and Sign the Arkansas State Board of Cosmetolgy New Establishment Application Form

Universal Data Collection U.S. Department of Health dddddddddd and Human Services Public Health Service CDC ID Baby Registration - - GENERAL INFORMATION Date of Visit month Date Form Completed day month year Data entered by: Form Completed by: day year CDC Use Only DEMOGRAPHIC INFORMATION 3. Race/Ethnicity: 1. Month and Year of Birth: Month 1a. Year 4. Place of Birth: White (non-Hispanic) State: White (Hispanic) Or, country: ________________ (if other than USA) Term Birth (>37 weeks) Black (non-Hispanic) Pre-term: ________ weeks Black (Hispanic) 2. Sex: 5. HTC Status: Asian/Pacific Islander Established Patient Male American Indian/Alaskan Native New Patient Female Other Transfer Patient DIAGNOSTIC INFORMATION 6. Factor deficiency type: VIII (Check all that apply. If patient IX 7. von Willebrand Other has vWD only, skip to #7) If yes, which type (select one) . 6a. Baseline factor activity: % check if < 1% 6b. Site of blood draw for factor activity: Cord blood Yes Venipuncture Type 1 Type 3 Type 2a Unknown Type 2b Other Unknown 8. Reason for diagnostic testing: 12. Method of delivery (check all that apply): Mother known carrier Other family history Vaginal Elective C-Section Bleeding symptom Unknown Forceps Vacuum Other ________________________ 9a. If prenatal, check diagnostic procedure: Chorionic villus sampling 9b. If there was a prenatal diagnostic procedure, was there a complication? No 10. Birth weight: Unknown lbs oz Yes No Other Unknown dd 14. Was clotting factor concentrate given within 24 hours of birth? Yes No 14a. If yes, reason: Unknown Prophylaxis 15. HTC contacted before delivery? 16. Has patient ever had a bleed? Unknown Other _______________________ Yes Unknown 13. Was vitamin K administered at birth? 9. Age bleeding disorder first diagnosed: days Prenatal months (Circle one) years Unknown Amniocentesis Non-elective C-Section Unknown Treatment of bleed Yes Yes 16a. If yes, age at first bleed: days months (Circle one) years 16b. If yes, site of first bleed: No Unknown No age unknown Head (Intracranial/Extracranial) Oral mucosa Circumcision Joint Intramuscular injection Unknown Other 11. Birth length: CDC 59.8F 1/2004 inches (Page 1 of 2) Unknown 17. Is another person with a bleeding DDD disorder living in the same household as the patient? Yes No Baby d Registration Form D BABY REGISTRATION FORM FORM COMPLETION: Complete this form one time only for each eligible patient under 2 years of age with hemophilia, von Willebrand disease, or other congenital bleeding disorder at the time that the first Baby Visit Form is completed. dddddddddd Patient CDC ID: The unique 12-digit number generated for each patient by staff at the hemophilia treatment center (HTC) using the CDC ID computer program. General Information: Enter the date of the visit and the date that this form was completed. Enter the initials of the person completing the form. 1. Month and year of birth: Enter the patient’s month and year of birth. Use leading zeros before single-digit months and days. 1a. If the baby was born at > 37 weeks gestation, check TERM BIRTH. If < 37 weeks, check PRE-TERM and enter the total number of weeks gestation. 2. Sex: Check MALE or FEMALE. 3. Race/Ethnicity: Check the racial/ethnic category that the parent/guardian considers the patient to be. Use the OTHER category to write in racial/ethnic groups not listed. 4. Place of Birth: Enter the place of birth by state (use state abbreviation; e.g., GA, CA) or country, if other than U.S.A. (See Data Forms Manual for state abbreviations) 5. HTC Status: Check ESTABLISHED PATIENT, if this patient has been seen at this HTC at least once in the past. Check NEW PATIENT, if the patient has never been seen at any HTC before. Check TRANSFER PATIENT, if the patient has been seen at another HTC but now plans to attend this HTC. 6. Factor deficiency type and 6a. Baseline factor activity and 6b. Site of blood draw for factor activity: Check factor deficiency type(s). If patient has vWD only, skip to #7. For patients with factor VIII or factor IX deficiency, enter the baseline factor activity and enter the site from which blood was obtained with which to establish baseline factor activity. 7. von Willebrand: Check YES, if the patient has been diagnosed with von Willebrand disease by a physician. If yes, check the multimeric analysis of the vWD. 8. Reason for diagnostic testing: Check all reasons that prompted diagnostic testing for a bleeding disorder. 9. Age bleeding disorder first diagnosed: Enter the age at which the patient received his/her current diagnosis. If the diagnosis was made at birth, enter 0 (zero) days for the age. If the diagnosis was made before birth, check box labeled PRENATAL. Designate DAYS, MONTHS, or YEARS as follows: indicate the number of days if age was less than 1 month; the number of months if age was 1 month or more but less than 1 year; or the number of years. If specific age is unknown, give approximate age. If approximate age is unknown, check box labeled UNKNOWN. 9a. If prenatal, check diagnostic procedure and 9b. If there was a prenatal diagnostic procedure, was there a complication: If the patient had his/her bleeding disorder diagnosed before birth, please check the diagnostic procedure that was performed. Also indicate whether or not a complication occurred (e.g., bleeding in the mother or the baby) either during or after the prenatal diagnostic procedure. If it is unknown whether a complication occurred, check UNKNOWN. 10. Birth weight and 11. Birth length: Enter the patient’s weight at birth in pounds and ounces and length at birth in inches. If the weight or length at birth is not known, check the appropriate UNKNOWN box. 12. Method of delivery: Check the appropriate method of delivery for the patient. If the method of delivery is unknown, check UNKNOWN. 13. Was vitamin K administered at birth? dd If vitamin K was administered to the patient within 24 hours of the birth, check YES. If there is no record of vitamin K administration at birth, check NO. If it is not known whether vitamin K was administered, check UNKNOWN. 14. Was clotting factor concentrate given within 24 hours of birth? and 14a. If yes, reason: Check YES, if the patient received any clotting factor concentrate (excluding blood bank and non-plasma products - see page 3 of Baby Visit Form) within 24 hours of the birth. Check NO, if the patient did not receive clotting factor concentrate during the first 24 hours of life. If it is not know whether or not the patient received clotting factor, check UNKNOWN. If yes, check PROPHYLAXIS if the factor infusion was given in the absence of a known bleed. Check TREATMENT OF BLEED if the factor infusion was given to stop a known or suspected bleed. 15. HTC contacted before the delivery? If either your HTC or another HTC was contacted by medical personnel concerning this baby prior to the birth, check YES. If there was no known contact between an HTC and medical care personnel concerning this baby prior to birth, check NO. If it is not known whether contact between an HTC and medical personnel concerning this baby occurred prior to birth, check UNKNOWN. 16. Has patient ever had a bleed and 16a. Age at first bleed: Check YES, if the patient has ever had a bleed that was unusual in either duration or amount. If yes, enter the age that the patient experienced the first bleeding episode. Note that this first bleeding episode may not have led to the diagnosis of a bleeding disorder. If the bleed occurred at birth, enter 0 (zero) days for the age. Designate DAYS, MONTHS, or YEARS as follows: indicate the number of days if age was less than 1 month; the number of months if age was 1 month or more but less than 1 year; or the number of years. If specific age is unknown, give approximate age. If approximate age is unknown, check box labeled AGE UNKNOWN. 16b. Site of first bleed: Check the site of the first bleed referred to in item 16a. Use the OTHER category to write in sites not listed. 17. Is another person with a bleeding disorder living in the same household as the patient: DDD Check YES, if another person with a congenital bleeding disorder is currently living in the same household as the patient. CDC 59.8F 1/2004 (Page 2 of 2) Baby d Registration Form D