ࡱ>  h#bjbj7H7H U"cU"c &> D!!!}!DyP/:000K1%4|5oCqCqCqCqCqCqC$FLICa6K1K1a6a6C00HDBBBa6F00oCBa6oCBBB0 J6FB[CD0DBJ6 JBJBa6a6Ba6a6a6a6a6CCBa6a6a6Da6a6a6a6Ja6a6a6a6a6a6a6a6a6 : New Jersey Department of Health Special Child Health and Early Intervention Services STATE BIRTH DEFECTS REGISTRY PO Box 364, Trenton, NJ 08625-0364BIRTH DEFECTS REGISTRY REGISTRATION Registration informationRegistration Type  FORMCHECKBOX New  FORMCHECKBOX Update  FORMCHECKBOX AuditFamily Informed of Registration  FORMCHECKBOX  Yes  FORMCHECKBOX NoType of Hospital/Reporting Facility  FORMDROPDOWN Registering Agency Name  FORMTEXT      Case Tracking informationMedical Record Number  FORMTEXT      Electronic Birth Certificate (EIN) No.  FORMTEXT      Insurance informationInsurance Type  FORMCHECKBOX None  FORMCHECKBOX Private  FORMCHECKBOX Medicaid  FORMCHECKBOX Unknownhospital/AGENCY contactName of Hospital/Agency Contact (Last, First, Middle, Suffix)  FORMTEXT      Job Title  FORMTEXT      Telephone Number ( FORMTEXT      )  FORMTEXT      Child s informationname of Child (as appears on birth certificate)Last Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMCHECKBOX  None Given  FORMTEXT      Middle Name  FORMTEXT      also known asLast Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMCHECKBOX  None Given  FORMTEXT      Middle Name  FORMTEXT      Child s current residence addressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      Hospital / Place of BirthMedical Facility Name or Description of Location  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Country  FORMTEXT      primary care provider after dischargePractice Name -OR- Provider Name (Last Name, First Name)  FORMTEXT       FORMCHECKBOX  Undecided  FORMCHECKBOX  UnknownTelephone Number Extension ( FORMTEXT      )  FORMTEXT        FORMTEXT      transfer informationChild Transferred  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDate of Transfer  FORMTEXT      Received From  FORMTEXT      Sent To  FORMTEXT       Child s information, continuedBirth informationDate of Birth  FORMTEXT      Sex  FORMCHECKBOX  Female  FORMCHECKBOX  Male  FORMCHECKBOX  IndeterminateBirthweight  FORMTEXT __________ Grams  OR-  FORMTEXT       Lbs.,  FORMTEXT       Ozs. -OR-  FORMCHECKBOX  UnknownPlurality  FORMCHECKBOX  Single  FORMCHECKBOX  Other Multiple:  FORMTEXT        FORMCHECKBOX  Twin  FORMCHECKBOX  UnknownBirth Order  FORMTEXT      Outcome  FORMCHECKBOX  LiveWeeks of Pregnancy  FORMCHECKBOX  Preterm (<37 Wks.)  FORMCHECKBOX  Post term (>42 Wks.)  FORMCHECKBOX  Term (37-41 Wks.)  FORMCHECKBOX  Unknownethnicity informationHispanic/Latino  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownPrimary Language Spoken in Home FORMCHECKBOX  English  FORMCHECKBOX  Spanish  FORMCHECKBOX  Other, Specify: FORMTEXT      Race (Check ALL that apply)  FORMCHECKBOX  White  FORMCHECKBOX  Black/African American  FORMCHECKBOX  Chinese  FORMCHECKBOX  American Indian/Native Alaskan  FORMCHECKBOX  Japanese  FORMCHECKBOX  Native Hawaiian  FORMCHECKBOX  Korean  FORMCHECKBOX  Filipino  FORMCHECKBOX  Vietnamese  FORMCHECKBOX  Guamanian or Chamorro  FORMCHECKBOX  Asian Indian  FORMCHECKBOX  Samoan FORMCHECKBOX  Other Asian, Specify: FORMTEXT       FORMCHECKBOX  Other Pacific Islander, Specify: FORMTEXT       FORMCHECKBOX  Other, Specify: FORMTEXT       FORMCHECKBOX  Not Classifiable / UnknownBIRTH MOTHER S RESIDENCE AT TIME OF BIRTHIF MOTHER WAS INSTITUTIONALIZED AT TIME OF BIRTH, ENTER RESIDENCE ADDRESS BEFORE SHE WAS INSTITUTIONALIZED  FORMCHECKBOX  Unknown  FORMCHECKBOX  Same as child s current residence addressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      death information FOR CHILDIs Expired?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDate of Death  FORMCHECKBOX  Unknown  FORMTEXT      Place of Death  FORMCHECKBOX  Unknown  FORMTEXT      Autopsy?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Pending  FORMCHECKBOX  UnknownDeath Certificate Number  FORMTEXT      PARENT A informationParent A Vital Status  FORMCHECKBOX  Alive  FORMCHECKBOX  Dead  FORMCHECKBOX  UnknownSex  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleBiological  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownpARENT A NameLast Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMTEXT      Middle Name  FORMTEXT      Maiden Name  FORMTEXT       Parent A information, continuedPARENT A mailing address FORMCHECKBOX  Same as child s current residence addressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. 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Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT       PARENT B information, continuedParent B Legal Guardian Status  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownDate of Birth  FORMTEXT      Telephone Number ( FORMTEXT      )  FORMTEXT        FORMCHECKBOX  No Phoneguardian agency informationLegal Guardian Status  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownGuardian Type  FORMCHECKBOX  Relative  FORMCHECKBOX  Individual (Non-Relative)  FORMCHECKBOX  Government Agency (DYFS, etc.)  FORMCHECKBOX  Private Agencyguardian agency InformationAgency Name  FORMTEXT      Division/Program  FORMTEXT      Street Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      guardian agency contact informationContact Name (Last Name, First Name)  FORMTEXT      Telephone Number ( FORMTEXT      )  FORMTEXT        FORMCHECKBOX  No PhoneGuardian s informationGuardian NameLast Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMTEXT      Middle Name  FORMTEXT      contact informationTelephone Number ( FORMTEXT      )  FORMTEXT        FORMCHECKBOX  No Phonemailing address FORMCHECKBOX  Same as child s current residence addressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT       DIAGNOSIS DESCRIPTION *TSB Reporting: *Date and Time *Date and Time (Be Specific) Type of Specimen Tested Specimen Collected Specimen Analyzed1. FORMTEXT      2. FORMTEXT      3. FORMTEXT      4. FORMTEXT      5. FORMTEXT      6. FORMTEXT      7. FORMTEXT      8. FORMTEXT           SCH-0 JUNAPR 07 Page  PAGE 3 of 2 Pages. SCH-0 JUL 17 Page  PAGE 1 of 2 Pages. 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