In order to comply with the D.C. Campaign Finance Reform and Public Financing of Elections Act of 2002, all candidates for office in the District of Columbia must file a Form Dch 1398 disclosure statement. This form provides detailed information about the individual's campaign finances, including expenditures, contributions, and debt incurred. The deadline for submitting this form is June 30th of each year. Any individual who fails to submit this form may be subject to a civil penalty up to $5,000 per day. Candidates who are not elected may also be required to pay back any money they received from the city during their campaign.
| Question | Answer |
|---|---|
| Form Name | Form Dch 1398 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | _PerinatalHepat itisBIntakeForm 040308_231888_7 hepatitis b vaccine intake form |
Perinatal Hepatitis B Intake Form
Fax to
Fax to
Woman’s name ________________________________ Date of birth ____________ Social Security # ______________
Address _________________________________________________ City _____________________ Zip ___________
County _______________ Telephone # _______________ Emergency contact name & # _________________________
Race: Asian/PI |
Black White |
Amer Indian Alaskan Native Other ____________ Unknown |
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Ethnicity: |
Hispanic |
Unknown |
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Grav ____ Para ____ Country of Birth _________________ Maternal Grandmother’s Country of Birth ______________
Does the woman need an interpreter Y N If yes, what language ___________________
Woman’s Laboratory Reports:
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(P = Positive/Reactive; N = |
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HBsAg _ / _ / _ |
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P |
N |
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NT U |
Repeat HBsAg |
_ / _ |
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/ _ |
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P |
N NT U |
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Date HBsAg reported |
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/ _ |
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How reported: |
OB |
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Hospital |
Other ______________ |
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HBeAg |
_ / _ |
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_ |
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P |
N |
NT |
U |
HBeAb |
_ / _ |
/ |
_ |
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P |
N |
NT |
U |
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_ / _ |
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P |
N |
NT |
U |
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P |
N |
NT |
U |
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HBV DNA |
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_ / _ |
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P |
N |
NT |
U |
HBV Viral Load __________ |
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Other maternal infections/conditions (HCV, HIV, Other STIs, etc) _________________________________________
LHD refer for care/evaluation? Y N U |
Hep B treatment during this pregnancy? |
Y |
N U |
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If yes, treatment brand/dose __________________ |
Treatment start date _ / _ / _ |
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Physician providing treatment _______________________________ Telephone # _________________ |
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Prenatal Care Provider (PCP) Information: |
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PCP/facility name ________________________________________________ EDC date _ |
/ _ / |
_ |
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Address _____________________________________________ City _________________________ Zip ___________
Telephone # ____________________ Hospital to deliver at _________________________________________________
Reporting information sent to PCP office? Y N Date _ / _ / __
Household/Sexual Contact Information:
First/Last Name |
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HBsAg, |
Test |
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DOB |
HBIG |
Hep B #1 |
Hep B #2 |
Hep B #3 |
and/or |
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(relationship) |
Date |
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Household/sexual contact provider name _______________________________________________________________
Address ___________________________ City ___________________ Zip __________ Telephone # ______________
CD Nurse _________________________________________ Telephone # ___________________________________
Rev 04/03/08 |