Pregnancy and Zika Virus Disease Surveillance Form - Neo

Form Approved
OMB Control No.: 0920-XXXX
Expiration date: XX/XX/XXXX

Pregnancy and Zika virus disease surveillance form
These data are considered confidential and will be stored in a secure database at the Centers for Disease Control and Prevention

Please return completed form by fax to (970) 266-3568 or email [email protected]

Neonate assessment at delivery
Infant’s name: ____________________________

DOB: _____/_____/_____

State of residence: __________________________

County of residence:_________________________

Sex:
Male

Female

Gestational age at delivery: ______ weeks

Apgar score: 1 min ____ / 5 min ____
Birth weight:

kg
lbs/oz

Infant temp at delivery: _______ oF Cord blood pH ___________

Length:
cm
in

Head circumference:

cm
in

Delivery type:
Vaginal
Forceps/suction
Caesarean section
Microcephaly
No

Yes

Neurologic abnormalities:
No
(please describe)

Splenomegaly:
No

Skin rash:
No

Maternal temp at delivery: ______°F

Admitted to NICU:

Yes

Yes

Dysmorphic features:
No
Yes
(please describe)

Yes (please describe)

Yes (please describe)

No

Hepatomegaly:
No

Yes (please describe)

Other abnormalities identified:
No
Yes
(please provide clinical description from medical
records)

-flip to back page 11

Form Approved
OMB Control No.: 0920-XXXX
Expiration date: XX/XX/XXXX

Pregnancy and Zika virus disease surveillance form
These data are considered confidential and will be stored in a secure database at the Centers for Disease Control and Prevention

Please return completed form by fax to (970) 266-3568 or email [email protected]

Neonate Imaging and Diagnostics
Hearing evaluation performed:
Normal

Abnormal (please describe)
Not Done

Ophthalmologic evaluation performed:
Normal

Abnormal (please describe)
Not Done

Placental exam (pathologist):
No
Yes
(please describe)

Imaging study result:
N/A
Normal

Abnormal
(please list type, date, and describe)

Lumbar puncture performed:
No
Yes
If yes,
Normal
Abnormal (please describe)

TORCH testing result:
Not Done
Negative

Positive (if positive, please specify pathogen and test
(e.g., PCR, IgG, IgM))

Other tests/results:

Provider Information
Provider name:
Dr.
PA
RN
Mr.
Ms.
___________________________________________

Phone: ________________________________
Email: _________________________________

Name of person completing form: (if different from provider) Hospital/facility: ______________________
_________________________________________
_______________________________________
_________________________________________
Phone:_________________________________
FOR INTERNAL CDC USE ONLY
Mother ID:

State ID:

Public reporting burden of this collection of information is estimated to average 15 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 E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

12