Prenatal Record - National Archives and Records Administration

PHS-3003-1, Obstetrical Adminiatrativ~
A.IMIN!8l'RATIVE RECORD MANUAL
.,:, ..,.
Record
AR-1
Rev. 7-6o
A. PURPOSE. This form provides for the registering, and notifying NINDE of
the registration; of each gravida in the sampling frame. The sampling
frame includes all patients who are eligible for inclusion in the study,
based on the sampling procedures approved for each institution. It also
provides the information needed for opening the case records of women
selected as study cases. In addition,. it provides for the reporting of
comparable administrative data for gravida in the sampling frame of the
institution, but who were not selected as study cases.
B. INTERVIEWER. The interviewer who completes the .form AR-1 may be any staff
member of the hospital trained to obtain and record the required information.
c. uriLIZATION. This form supersedes Form OB-1 (R~v. 7/59) which will not be
used after receipt of sqpplies of Form AR-1.
D. INSTRUCTIONS FOR COMPLETING FORM AR-1.
Item 1, Patient Identification. Patient NINDE study number is entered here
for all study cases. It may be entered by Addressograph, other stamp or
written. The number must be completely legible on the copy sent to NINDE.
This item is left blank for patients in the sampling frame who are not
selected for the study.
Item 2, Last Name.
Item 3, OPD Number.
Last name of patient.
OUt-patient Department number if assigned to patient.
Item 4, Hospital Number.
Regular hospital number if assigned to patient.
Item 5, Special Number. Any special identifying number assigned by the
hospital to the patient. If none, leave blank.
Item 6, First Name.
Item 7, Middle Name.
Self-explanatory.
If none, leave blank or write the code "NMI".
Item 8, Maiden Name. As reported. If patient is single (Item 17 coded "S"),
malden name will be reported in Item 2 (Last Name); therefore place an
"X" in Item 8 (Maiden Neme). If a patient with other marital status is
using her maiden name as her last name place an "X" in Item 8 and indicate
reason, if known in item 8.
Department of Health, EducatiOn, and Welfare
Pub~ic Hea~th Service
October 1, 1960
II.A.lO
AR-1
Reproduced at the National Archives