Chart Abstraction

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: ________________________

Infant History

Pregnancy History (if noted)

Infant Date of Birth (d/m/y)

__ __/ __ __/ __ __ __ __

Mother Date of Birth (d/m/y)

__ __/ __ __/ __ __ __ __

Date microcephaly diagnosed (d/m/y)

__ __/ __ __/ __ __ __ __

Total number of previous

___ Live births

Sex:

 Male

 Female

 Ambiguous

____ Still births

____ Spontaneous abortions

Gestational age at birth

_______(in weeks)

Birth weight:

____________(in grams)

Are the parents related?

 Yes

 No

Birth length:

____________(in cm)

If yes, explain:______________________

Birth head circumference

____________(in cm)

Date (d/m/y) and time (hh:mm) of measurements

__ __/ __ __/ __ __ __ __ __ __: __ __

Prenatal testing and history

Prenatal ultrasound

 Yes

 No

Multiple birth:

 Yes

 No

Results:  Normal  Abnormal; describe:____________ _______________________________________________

If yes, specify: __________________________________

Prenatal amnio

 Yes

 No

Results:  Normal  Abnormal; describe:____________ ______________________________________________

Medical problems

Chorionic villus sampling

 Yes

 No

 Hearing problems

 Blindness

Results:  Normal  Abnormal; describe:____________ ______________________________________________

 Seizures  Sepsis

 Difficulty swallowing  Respiratory distress

 Other, describe: __________________________________ __________________________________________________ __________________________________________________

Underlying medical conditions during this pregnancy: ______________________________________________ ______________________________________________

Imaging and test results for infant

Any complications with this pregnancy:

Neuroimaging performed:

 Yes

 No

______________________________________________ ______________________________________________

Record results noting scan type: _______________________ __________________________________________________ __________________________________________________

Maternal medications during this pregnancy: ______________________________________________ ______________________________________________

Genetic testing performed:

 Yes

 No

Record results noting test type: ________________________ __________________________________________________ __________________________________________________

Any noted maternal exposures (e.g., toxins, chemicals): ______________________________________________ ______________________________________________

Infectious disease testing for infant

Infectious disease testing performed during this pregnancy

VDRL

 Yes

 No

VDRL

 Yes

 No

Is yes

 Reactive

 NR

Is yes

 Reactive

 NR

CMV

 Yes

 No

CMV

 Yes

 No

If yes

 Positive IgM  Positive IgG  Positive cx

 Negative IgM  Negative IgG  Negative cx

If yes

 Positive IgM  Positive IgG  Positive cx

 Negative IgM  Negative IgG  Negative cx

HSV 1

 Yes

 No

HSV 1

 Yes

 No

If yes

 Positive IgM  Positive IgG  Positive cx

 Negative IgM  Negative IgG  Negative cx

If yes

 Positive IgM  Positive IgG  Positive cx

 Negative IgM  Negative IgG  Negative cx

HSV 2

 Yes

 No

HSV 2

 Yes

 No

If yes

 Positive IgM  Positive IgG  Positive cx

 Negative IgM  Negative IgG  Negative cx

If yes

 Positive IgM  Positive IgG  Positive cx

 Negative IgM  Negative IgG  Negative cx

Rubella

 Yes

 No

Rubella

 Yes

 No

If yes

 Positive IgM  Positive IgG

 Negative IgM  Negative IgG

If yes

 Positive IgM  Positive IgG

 Negative IgM  Negative IgG

Toxoplasmosis

 Yes

 No

Toxoplasmosis

 Yes

 No

 Positive

 Negative

 Positive

 Negative

Dengue

 Yes

 No

Dengue

 Yes

 No

If yes

 Positive RNA  Positive IgM  Positive IgG

 Negative RNA  Negative IgM  Negative IgG

If yes

 Positive RNA  Positive IgM  Positive IgG

 Negative RNA  Negative IgM  Negative IgG

Zika

 Yes

 No

Zika

 Yes

 No

If yes

 Positive RNA  Positive IgM  Positive IgG

 Negative RNA  Negative IgM  Negative IgG

If yes

 Positive RNA  Positive IgM  Positive IgG

 Negative RNA  Negative IgM  Negative IgG

Chikungunya

 Yes

 No

Chikungunya

 Yes

 No

If yes

 Positive RNA  Positive IgM  Positive IgG

 Negative RNA  Negative IgM  Negative IgG

If yes

 Positive RNA  Positive IgM  Positive IgG

 Negative RNA  Negative IgM  Negative IgG

Other 1:_________ ________________

 Yes

 No

Other 1:_________ _______________

 Yes

 No

Results: _________________________________________

Results: _______________________________________

Other 2: ________ ________________

 Yes

 No

Other 2: ________ ______________

 Yes

 No

Results: _________________________________________

Results: _______________________________________

Other infant examinations or abnormalities/defects

Results of infant eye exam:  Normal  Abnormal, describe: _________________________________________________

_______________________________________________________________

Birth defect present

Full description of defect

Area to describe specific test results or defects in more detailed, if not captured above

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)