Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Appendix 2. Chart Extraction
Microcephaly Case Control Investigation |
Infant case ID: _______-A-2 Date of extraction:__ __/ __ __/ __ __ __ __ day month year |
Name of healthcare facility:_____________ Town/City: _________________________ Municipality: ________________________ |
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Infant History |
Pregnancy History (if noted) |
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Infant Date of Birth (d/m/y) |
__ __/ __ __/ __ __ __ __ |
Mother Date of Birth (d/m/y) |
__ __/ __ __/ __ __ __ __ |
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Date microcephaly diagnosed (d/m/y) |
__ __/ __ __/ __ __ __ __ |
Total number of previous |
___ Live births |
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Sex: |
Male |
Female |
Ambiguous |
____ Still births |
____ Spontaneous abortions |
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Gestational age at birth |
_______(in weeks) |
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Birth weight: |
____________(in grams) |
Are the parents related? |
Yes |
No |
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Birth length: |
____________(in cm) |
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If yes, explain:______________________ |
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Birth head circumference |
____________(in cm) |
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Date (d/m/y) and time (hh:mm) of measurements |
__ __/ __ __/ __ __ __ __ __ __: __ __ |
Prenatal testing and history |
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Prenatal ultrasound |
Yes |
No |
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Multiple birth: |
Yes |
No |
Results: Normal Abnormal; describe:____________ _______________________________________________ |
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If yes, specify: __________________________________ |
Prenatal amnio |
Yes |
No |
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Results: Normal Abnormal; describe:____________ ______________________________________________
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Medical problems |
Chorionic villus sampling |
Yes |
No |
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Hearing problems |
Blindness |
Results: Normal Abnormal; describe:____________ ______________________________________________ |
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Seizures Sepsis |
Difficulty swallowing Respiratory distress |
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Other, describe: __________________________________ __________________________________________________ __________________________________________________ |
Underlying medical conditions during this pregnancy: ______________________________________________ ______________________________________________ |
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Imaging and test results for infant |
Any complications with this pregnancy: |
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Neuroimaging performed: |
Yes |
No |
______________________________________________ ______________________________________________
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Record results noting scan type: _______________________ __________________________________________________ __________________________________________________ |
Maternal medications during this pregnancy: ______________________________________________ ______________________________________________ |
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Genetic testing performed: |
Yes |
No |
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Record results noting test type: ________________________ __________________________________________________ __________________________________________________ |
Any noted maternal exposures (e.g., toxins, chemicals): ______________________________________________ ______________________________________________ |
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Infectious disease testing for infant |
Infectious disease testing performed during this pregnancy |
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VDRL |
Yes |
No |
VDRL |
Yes |
No |
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Is yes |
Reactive |
NR |
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Is yes |
Reactive |
NR |
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CMV |
Yes |
No |
CMV |
Yes |
No |
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If yes |
Positive IgM Positive IgG Positive cx |
Negative IgM Negative IgG Negative cx |
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If yes |
Positive IgM Positive IgG Positive cx |
Negative IgM Negative IgG Negative cx |
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HSV 1 |
Yes |
No |
HSV 1 |
Yes |
No |
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If yes |
Positive IgM Positive IgG Positive cx |
Negative IgM Negative IgG Negative cx |
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If yes |
Positive IgM Positive IgG Positive cx |
Negative IgM Negative IgG Negative cx |
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HSV 2 |
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Yes |
No |
HSV 2 |
Yes |
No |
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If yes |
Positive IgM Positive IgG Positive cx |
Negative IgM Negative IgG Negative cx |
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If yes |
Positive IgM Positive IgG Positive cx |
Negative IgM Negative IgG Negative cx |
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Rubella |
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Yes |
No |
Rubella |
Yes |
No |
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If yes |
Positive IgM Positive IgG |
Negative IgM Negative IgG |
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If yes |
Positive IgM Positive IgG |
Negative IgM Negative IgG |
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Toxoplasmosis |
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Yes |
No |
Toxoplasmosis |
Yes |
No |
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Positive |
Negative |
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Positive |
Negative |
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Dengue |
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Yes |
No |
Dengue |
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Yes |
No |
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If yes |
Positive RNA Positive IgM Positive IgG |
Negative RNA Negative IgM Negative IgG |
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If yes |
Positive RNA Positive IgM Positive IgG |
Negative RNA Negative IgM Negative IgG |
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Zika |
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Yes |
No |
Zika |
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Yes |
No |
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If yes |
Positive RNA Positive IgM Positive IgG |
Negative RNA Negative IgM Negative IgG |
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If yes |
Positive RNA Positive IgM Positive IgG |
Negative RNA Negative IgM Negative IgG |
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Chikungunya |
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Yes |
No |
Chikungunya |
Yes |
No |
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If yes |
Positive RNA Positive IgM Positive IgG |
Negative RNA Negative IgM Negative IgG |
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If yes |
Positive RNA Positive IgM Positive IgG |
Negative RNA Negative IgM Negative IgG |
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Other 1:_________ ________________ |
Yes |
No |
Other 1:_________ _______________ |
Yes |
No |
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Results: _________________________________________ |
Results: _______________________________________ |
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Other 2: ________ ________________ |
Yes |
No |
Other 2: ________ ______________ |
Yes |
No |
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Results: _________________________________________ |
Results: _______________________________________ |
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Other infant examinations or abnormalities/defects |
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Results of infant eye exam: Normal Abnormal, describe: _________________________________________________ |
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_______________________________________________________________ |
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Birth defect present |
Full description of defect |
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Area to describe specific test results or defects in more detailed, if not captured above
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Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
File Type | application/msword |
File Title | Emergency Epidemic Investigations |
Author | lmp2 |
Last Modified By | Eaton, Danice (CDC/OPHSS/CSELS) |
File Modified | 2016-02-11 |
File Created | 2016-02-04 |