Download:
pdf |
pdfZika Virus Disease Case Investigation Form
Arboviral Diseases Branch
Version 3.1
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
FOR CDC USE ONLY
CDC R-number______________________________
ZIKVID:__________________
CDC staff initial:_____________________________
Date form completed:_____/_____/_____
CDC investigating group:______________________
Reporting Jurisdiction
Jurisdiction (state/territory):________
Agency:_______________________________
Contact Name:___________________________
Contact Phone:_________________________
Contact Position:_________________________
Contact Email:__________________________
Alternate Contact Name:___________________
Alternate Contact Phone:_________________
Demographic Information
State of residence:___________
State patient ID number:_______________________
Patient last name: _____________________
Patient first name: _____________________
Age: ______ Years Months Days
Sex: Male Female
Travel History
Dates of travel: ____________________
Country(s) visited:____________________________________________________________________________
Vaccination History
Previously vaccinated for:
Yellow Fever Japanese Encephalitis Tick-borne Encephalitis
Cases of Special Interest
Please indicate if patient meets any of the following criteria:
Local vector-borne transmission
Yes No
Pregnant
Yes No Unknown
If yes: Current gestational week:_____
Gestational week at illness onset (if applicable): _____
Fetal loss
Yes No
If yes: Gestational week at time of fetal loss:______
Microcephaly
Yes No
Suspect
Guillain-Barre syndrome/acute flaccid paralysis
Yes No
Suspect
Sexual transmission
Yes No
Suspect
Blood/blood product transfusion transmission
Yes No
Suspect
Organ/tissue transplant transmission
Yes No
Suspect
Breastfeeding transmission
Yes No
Suspect
Page 1 of 2
Suspect
Public reporting burden of this collection of information is estimated to average 10 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)
February 5, 2016
Zika Virus Disease Case Investigation Form
Arboviral Diseases Branch
Version 3.1
Illness Information
Illness onset date: _____/_____/_____
Fever
Hospitalized
Died
Yes No
If yes: Subjective fever Measured fever (Maximum measured temperature: _____)
Rash
Yes No
If yes: Type:
Maculopapular Petechial
Purpuric Other
Pruritic: Yes No
Distribution:______________________________________________
Arthralgia
Myalgia
Oral ulcers
Conjunctivitis
Vomiting
Hematospermia (for males)
Headache
Diarrhea
Peripheral edema
Specimen Information
Specimen 1 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 2 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 3 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 4 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 5 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 6 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 7 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Page 2 of 2
February 5, 2016
| File Type | application/pdf |
| File Title | Microsoft Word - Zika Virus Clinical Questionnaire_v3.1 |
| Author | frd3 |
| File Modified | 2016-02-10 |
| File Created | 2016-02-05 |