EPID 399 is the Kentucky Department for Public Health's perinatal hepatitis B prevention form, linking a hepatitis B surface antigen (HBsAg) positive pregnant or postpartum mother with her exposed newborn. A delivering hospital or obstetric provider meets it when the mother tests HBsAg-positive or her status is unknown at birth. It documents the mother's test result and the infant's hepatitis B vaccine and HBIG doses.
The obstetric provider or delivering hospital completes the mother's section, and nursing staff record the infant's hepatitis B vaccine and HBIG with an RN signature. A parent signs the consent or refusal block.
Download the current version from the source each time; forms change without notice.
Kentucky Reportable Disease Form: Perinatal Hepatitis B Prevention Form for Exposed Infants and Hepatitis B Positive Pregnant Mothers
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Within 1 day of birth. The form tells the hospital to fax a copy of EPID 399, with the mother's lab results, to the health department where the family resides. It applies to infants born to HBsAg-positive mothers and to infants whose mothers' HBsAg status is unknown.
EPID 399 has a parent consent or refusal block at the bottom, with the parent's signature, the reason, and the date and time. Record the refusal there and fax the form to the health department within 1 day of birth, as for any other exposed infant.