Pregnancy and Zika Virus Disease Surveillance Form

State/Territory ID ___________________________ Approved

OMB No. 0920-1101

Exp. 08/31/2016

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 sending an encrypted email to [email protected] or by fax to the secure number: 404-718-2200. Pregnancy & Birth Defects Task Force phone number: 770-488-7100
Mother’s Zika virus infection (ADB follow-up)
Mother’s name:	________________________________________________________________ Last First MI										____________________ Maiden name (if applicable)
State/Territory ID: ________________________________					DOB: _______/_______/________				State/Territory of residence: _______________________
County of residence: ______________________					Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Race (check all that apply):  American Indian or Alaska Native  Asian  Black or African-American  Native Hawaiian or other Pacific Islander  White
Indication for maternal Zika virus testing:  Exposure history, no known fetal concerns  Exposure history and fetal concerns
Date of Zika virus symptom onset: _____/_____/_____ OR-  Asymptomatic If date not known, trimester of symptom onset _________________ Hospitalized for Zika virus disease  No  Yes Maternal Death  No  Yes
Symptoms of mother’s Zika virus disease: (check all that apply)  Fever _____oF (if measured)  Rash  Arthralgia  Conjunctivitis  Other Clinical Presentation_________________________________________________________________________
If symptomatic, gestational age at onset: ___________________weeks If gestational age not known ,trimester of symptom onset _________________								Travel history:  No  Yes
Was Zika virus infection acquired in place of residence  No  Yes, if yes, skip to the section on Mother’s pregnancy
If TRAVEL DURING PREGNANCY, answer questions below. If not, skip to non-traveling woman
Country(s) of exposure (1)_________________					Travel start _____/_____/_____					Travel end____/_____/_____
Mother’s sexual partner(s)? please check all that apply  Male  Female
Did any male sexual partner(s) travel on this trip?  No  Yes  Unknown
If yes, did any male partner(s) have an illness that included fever, rash, arthralgia, or conjunctivitis during or within 2 weeks of travel?  No  Yes  Unknown If yes, was there unprotected sexual contact while male partner(s) had illness?  No  Yes  Unknown
If male partner(s) traveled, did he have a test that showed lab evidence of Zika?  No  Yes  Unknown
Country(s) of exposure (2)_________________					Travel start _____/_____/_____					Travel end____/_____/_____
Mother’s sexual partner(s)? please check all that apply  Male  Female
Did any male sexual partner(s) travel on this trip?  No  Yes  Unknown
If yes, did any male partner(s) have an illness that included fever, rash, joint pain, or pink eye during or within 2 weeks of travel?  No  Yes  Unknown If yes, was there unprotected sexual contact while male partner(s) had illness?  No  Yes  Unknown
If male partner(s) traveled, did he have a test that showed lab evidence of Zika?  No  Yes  Unknown
Country(s) of exposure (3)_________________					Travel start _____/_____/_____					Travel end____/_____/_____
Mother’s sexual partner(s)? please check all that apply  Male  Female
Did any male sexual partner(s) travel on this trip?  No  Yes  Unknown
If yes, did any male partner(s) have an illness that included fever, rash, joint pain, or pink eye during or within 2 weeks of travel?  No  Yes  Unknown If yes, was there unprotected sexual contact while male partner(s) had illness?  No  Yes  Unknown
If male partner(s) traveled, did he have a test that showed lab evidence of Zika?  No  Yes  Unknown
NON-TRAVELLING WOMAN: other possible exposures?
 Sexual partner w/travel history, symptomatic, lab evidence of Zika  Sexual partner w/travel history, symptomatic, no test results    Sexual partner w/travel history, asymptomatic, lab evidence Zika  Other, please describe_____________________________________________________________________________  Unknown exposure history
Mother’s pregnancy (DRH/DBDDD follow-up)
Last menstrual period (LMP): _____/_____/_____								Estimated delivery date: _____/_____/_____
Estimated delivery date based on (check all that apply):  LMP ___/___/___  U/S (1st trimester)  U/S (2nd trimester)  U/S (3rd trimester)
History: # pregnancies _____ # living children _____ # miscarriages _____ # elective terminations _____
Prior fetus/infant with microcephaly:  No  Yes If yes, genetic cause:  No  Yes
Gestation:  Single  Twins  Triplets+
Underlying maternal illness: Diabetes  No  Yes  Maternal PKU  No  Yes Hypothyroidism  No  Yes Hypertension  No  Yes Substance use during this pregnancy: Alcohol use  No  Yes Cocaine use  No  Yes Smoking  No  Yes Other underlying illness:  ___________________________________________________
Complications of pregnancy:
Toxoplasmosis  Negative  Positive  Unknown Cytomegalovirus  Negative  Positive  Unknown Herpes Simplex  Negative  Positive  Unknown Rubella  Negative  Positive  Unknown Syphilis  Negative  Positive  Unknown
Fetal genetic abnormality  No  Yes, diagnosis __________________________ Unknown
Gestational diabetes  No  Yes				Pregnancy-related HTN  No  Yes			Intrauterine death of a twin  No  Yes
Other _________________________________________________________________________________
Medications during pregnancy:  No  Yes (please list type and see guide for further instructions)
Did this pregnancy end in miscarriage or intrauterine fetal demise (IUFD)?  No  Yes Date: _____/_____/_____ Gestational age_______ weeks						Was this pregnancy terminated?  No  Yes Date: _____/_____/_____ Gestational age______ weeks
Maternal Prenatal Imaging and Diagnostics
Date(s) of Ultrasound(s):
____/____/____  check if date approximated if date not known, gestational age ______ weeks			Overall Fetal Ultrasound Results:  Normal  Abnormal  reported by patient/healthcare provider  ultrasound report Head Circumference _______cm  Normal  Abnormal (by physician report) Biparietal diameter ______cm Femur Length _____cm Abdominal circumference _____cm  Symmetrical intrauterine growth restriction (IUGR) (<5% EFW)  Asymmetrical IUGR (HC<FL or HC <AC)
			Intracranial calcifications  No  Yes Ventriculomegaly  No  Yes
			Cerebral atrophy  No  Yes Ocular anomalies  No  Yes
			Cerebellar abnormalities  No  Yes Arthrogryposis  No  Yes
			Lissencephaly  No  Yes Pachygyria  No  Yes Hydranencephaly  No  Yes Porencephaly  No  Yes Corpus callosum abnormalities  No  Yes Hydrops  No  Yes
			Ascites  No  Yes Other  No  Yes, describe
Description of abnormal ultrasound findings:
____/____/____  check if date is approximated if date not known, gestational age ______ weeks			Overall Fetal Ultrasound Results:  Normal  Abnormal  reported by patient/healthcare provider  ultrasound report Head Circumference _____cm  Normal  Abnormal (by physician report) Biparietal diameter ______cm Femur Length _____cm Abdominal circumference _____cm  Symmetrical IUGR (<5% EFW)  Asymmetrical IUGR (HC<FL or HC <AC)
			Intracranial calcifications  No  Yes Ventriculomegaly  No  Yes
			Cerebral atrophy  No  Yes Ocular anomalies  No  Yes
			Cerebellar abnormalities  No  Yes Arthrogryposis  No  Yes
			Lissencephaly  No  Yes Pachygyria  No  Yes Hydranencephaly  No  Yes Porencephaly  No  Yes Corpus callosum abnormalities  No  Yes Hydrops  No  Yes
			Ascites  No  Yes Other  No  Yes, describe
Description of abnormal ultrasound findings:
____/____/____  check if date is approximated if date not known, gestational age ______ weeks			Overall Fetal Ultrasound Results:  Normal  Abnormal  reported by patient/healthcare provider  ultrasound report Head Circumference _____cm  Normal  Abnormal (by physician report) Biparietal diameter ______cm Femur Length _____cm Abdominal circumference _____cm  Symmetrical IUGR (<5% EFW)  Asymmetrical IUGR (HC<FL or HC <AC)
			Intracranial calcifications  No  Yes Ventriculomegaly  No  Yes
			Cerebral atrophy  No  Yes Ocular anomalies  No  Yes
			Cerebellar abnormalities  No  Yes Arthrogryposis  No  Yes
			Lissencephaly  No  Yes Pachygyria  No  Yes Hydranencephaly  No  Yes Porencephaly  No  Yes Corpus callosum abnormalities  No  Yes Hydrops  No  Yes
			Ascites  No  Yes Other  No  Yes, describe
Description of abnormal ultrasound findings:
For additional ultrasounds, please request a supplementary ultrasound form
Fetal MRI performed:  No  Yes (please answer questions below)
____/____/____  check if date is approximated if date not known, gestational age ______ weeks		Overall Fetal MRI Results:  Normal  Abnormal  reported by patient/healthcare provider  ultrasound report Head Circumference ___cm  Normal  Abnormal (by physician report) Biparietal diameter ______cm Femur Length _____cm Abdominal circumference _____cm  Symmetrical IUGR (<5% EFW)  Asymmetrical IUGR (HC<FL or HC <AC)
		Intracranial calcifications  No  Yes Ventriculomegaly  No  Yes
		Cerebral atrophy  No  Yes Ocular anomalies  No  Yes
		Cerebellar abnormalities  No  Yes Arthrogryposis  No  Yes
		Lissencephaly  No  Yes Pachygyria  No  Yes Hydranencephaly  No  Yes Porencephaly  No  Yes Corpus callosum abnormalities  No  Yes Hydrops  No  Yes
		Ascites  No  Yes Other  No  Yes, describe
Description of abnormal MRI findings:
Amniocentesis performed:  No  Yes (date: _____/_____/_____ ) Zika virus testing:  Not performed  Yes, if yes test results:  negative for Zika  lab evidence of Zika Non-Zika infection detected  No  Yes if yes, what infection(s) detected_____________________________ Genetic abnormality detected  No  Yes Please Describe:
Provider Information
Provider name:  Dr.  PA  RN  Mr.  Ms. _____________________________________________________ Last First MI Phone: _______________ Email: ________________________ Date of form completion _____/_____/____
Name of person completing form: (if different from provider) _____________________________________________ Last First MI Hospital/facility:____________________________________________________________________________________ Phone: _______________ Email: ________________________ Date of form completion _____/_____/____
Health Department Information
Name of person completing form: _____________________________________________________________________ Phone: _______________ Email: ________________________ Date of form completion _____/_____/____
FOR INTERNAL CDC USE ONLY Mother ID: State/Territory ID: Zika T ID:
R number: _____________ Mother infection type:  Confirmed  Probable  Possible
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 (0920-1101).