A. General Data
1. Reporting Source Identifying Information
2. Date of Report
3. Parental Consent Information
4. Referral Information
5. Identifying Information of Person Completing Birth Defects Registry Form
B. Information About the Child
1. Medical Record Number
2. Name and Address, with parent and guardian written consent as provided in s. DHS 116.04 (2) (d). 3. Date of Birth
4. Birth Circumstances
5. Race/Ethnicity
6. Sex
7. Place of Birth
8. Identifying Information of Primary Care Provider
9. Date of Diagnosis
10. Suspected or Confirmed Defects
11. Identifying Information of Physician Making Diagnosis
12. Prenatal Diagnostic Information
13. Child Status Information
C. Information About the Mother
1. Name
2. Date of Birth
3. Race/Ethnicity
4. Residence Location at Time of Child’s Birth
D. Information About the Father
1. Name
2. Date of Birth
3. Race/Ethnicity
1 The core data items are based on recommendations of the Centers for Disease Control and Prevention’s National Center for Health
Statistics.
