1.Clientname(first, middle, last)______/ 2.ClientNumber:
3. Birthdate(DD/MM/YYYY)
/ _/ / 4.Datetoday (DD/MM/YYYY)
/ _/ / 5.Infant’sagetoday (days)
6. FacilityName(Namein full):
7. Sub-County ofresidence:
8. Placeof birth: / □Home □Healthfacility□Other(specify):
9.Referred from(tick one): / □Self-referral □ANC □Maternity □Delivery □Pediatricward
□Pediatricoutpatient □Other(specify):
10.Parent/guardian name:(tick all that apply) / □Mother:
□Father:
□Guardian:
11.Telephonenumber:
CONSENT STATUS
12.Written informedconsent
obtained?(tickone) / □YES □NO(MC should not be performed)
13.Written Consent obtainedfrom
(mandatory) / □Mother □Father □Guardian
MEDICALHISTORY
14.Mother’sHIV status:
(If unknown, offertestingorrefer motherandinfant asappropriate. Documentreferrals on finalpage. Do not delay circumcisiondue tomother’s HIV+ or unknownstatus). / HIV testdate (DD/MM/YYYY):
Result (tickone): □ Negative □New positive
□Unknown □Known positive; in care
Negative HIV test must be documented. If obtained more than 3 months ago, repeat as per national guidelines.
15. VitaminKadministered?(tickone)
(Do not circumciseinfant8 days
without 1 dose Vitamin K today or earlier) / □YES (Administeredtoday)
□YES (Administeredatbirth)
□NO
16. Has the baby passed urine?(tickone)
(Do not circumciseif urination not reported) / □YES □NO
17. Mother has documentation of or reports: two prior TT doses of which at least one was this pregnancy, OR three prior TT doses with none this pregnancy / □YES □NO
Note: If any answer below is yes, do not circumcise
18.Familyorinfanthistoryof
bleeding disorder(excessive bleeding with surgery, minor injury, tooth extractions) / □YES □NO
19.Infanthistoryofconvulsion / □YES □NO
20.Otherseriousmedical
condition(a previoushealth issue isnotaproblemifinfantis well) / □YES □NO
Note:If any answerbelowisyes, do notcircumcise and referasappropriateand documentreferral onfinal page
PHYSICAL EXAM/ELIGIBILITY / Checkone
Yes / No
22. Current weight_____kg Too low for age per job aid? (WHOchildgrowthstandards)
23.Lessthan 37weeks corrected gestational age(if unknown, use other criteria)
24.Infant<12 hours or > 60daysold
25.Any vital signsoutside normal
rangeswhen baby is calm / Temperature(C): (36.5o–37.5oC)
Respiratoryrate(b/min): (30-60 b/min)
Heartrate(bpm): ______(120–160bpm)
26.Unwell-appearingor poorly responsive
27.Medicalcontraindication(specify):
(includes jaundice oricterus, loud heartmurmurorotherabnormal heartsounds,petechiae or multiple bruises,crackles orotherabnormal lungsounds)
28.Anatomic abnormality(specify):
(includespenile torsion,medianraphe not midline,hypospadiasorepispadias,abnormal urethra, buriedpenis,penile length <1cm,penilescrotal web, hydrocele, dorsal hood, abnormal scrotalruggae, foreskinabnormality, othergenitalabnormality)
EIMCPROCEDURE
29. Date of procedure:
30.StartTime: / Procedurestarted at: _: (in 24hrs)
31.EndTime: / Procedureended at: : (in24hrs)
32.Pre-operativemedication: / Medication: □Paracetamol (give 15mg/Kg bodyweight) □ other: ______
Dose: (refer tojob aidfordosage)
33.Anesthesia: / Concentration and dose(tickone and fill in dose):
□Lidocaine1% mL(maximum safe dose 0.3mL/kg)
□Lidocaine2% mL(maximum safe dose 0.15mL/kg) diluted to total volume of 1 mL using sterile water for injection
34.Procedure / Technique(tickone):
□dorsal penile nerveblock □Other(specify______
Device(tickone):
□Mogen Clamp □Other(specify)_
35.IntraoperativeAdverse
Events / Intraoperativeadverseevents: □Yes □No
AdverseEventType:
AdverseEventSeverity:
□Mild □Moderate □Severe
(documentmanagementofall AEs andreferralsonthe clinical notespage)
36.NameofSurgeon:Last Name OtherNames
37.Cadre: □MO □CO □NO 38.Surgeon Signature:______
39.NameofAssistantSurgeon:LastName OtherNames_
40.Cadre: □MO □CO □NO 41.Assistant Surgeon Signature:______
POST-OPERATIVEFOLLOWUP
42.Dateof Review:
43.Typeof Follow-Up / □ Day3 □ Other(specify)
44.Vital Signs: / Temp. Heartrate bpm Respiratoryrate: b/min
46. Infant well-being / Has infant had poor feeding, fussiness or diminished urination? □YES □NO
45.AdverseEvent reported: / Adverse event or abnormality in wound appearance? □YES □NO
AdverseEventType(enterAE Code):
(refer to theAE descriptionform)
AdverseEventSeverity:
□Mild □Moderate □Severe
(DocumentmanagementofallAEs andreferralsonthe clinical notespage)
46.NameofReviewingOfficer:LastName OtherNames_
47.Cadre: □M.O. □C.O. □N.O. ReviewingOfficer Signature:
48. Return visit needed? □NO □YES, if yes when? Date______
REFERRALS
49.ReferralDate: (DD/MM/YYYY) / /
50.Referred to(tickallthat
apply):
(Infant should be referred when appropriate without regard to whether he is circumcised this day.) / □PNC
□Infantsixweeksabovefordried blood spot for HIV testing
□HIVCareTreatment
□Pediatricoutpatientorwardfor EIMCcomplication
□Pediatricoutpatientor wardfor non-EIMCissue(specify): ______
□Other(specify):
51.Referralfacilityname:
52: Clinical notes:
______
______
______