Pregnancy and Zika Virus Disease Surveillance Form - Inf

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]

Infant follow up:

2 months

6 months

Infant’s name: ______________________________________
Weight:

kg
lbs/oz

Infant physical exam:
Normal
Infant development:
Normal

cm
in

Length:

12 months
Date of exam: ____/____/____
Head circum:_______

cm
in

Abnormal (please describe)

Abnormal (please describe)

Special Studies Since Last Follow-Up
(Please summarize any results)
CT/other imaging scan:
Yes

No

Hearing evaluation performed:
Yes

Dysmorphology exam:
Yes

No

Ophthalmologic exam:
Yes

No

Other (please describe):
Yes

No

No

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)

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