Pregnancy and Zika virus disease surveillance form - Neo

Infant’s State/Territory ID____________________ Mother’s 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 phone number: 770-488-7100

Neonate Assessment

Infant’s name: ___________________________________________________________ Last First MI

Birth Certificate ID: ________________

Infant’s State/Territory ID __________________

Mother’s State/Territory ID ____________________

DOB: _____/_____/______

Sex:  Male  Female

 Ambiguous/undetermined

Gestational age at delivery: ______ weeks ______ days

Based on: (check all that apply)  LMP ___/___/___  U/S (1^st trimester)  U/S (2^nd trimester)  U/S (3^rd trimester)  Other_______________

State/Territory of residence: ______________________________

County of residence: _____________________

Delivery type:  Vaginal  Caesarean section

Delivery complication:  No  Yes

If yes, _________________________________________

Arterial Cord blood pH: if performed _________

Venous Cord blood pH: if performed _________

Placental exam (based on path report):  No  Yes

If yes,  Normal  Abruption  Inflammation  Other abnormality (please describe)

Apgar score: 1 min ________ / 5 min _________

Infant temp (if abnormal): _______ ^oF

Physical Examination

Birth head circumference: _______ cm ________ in

 molding present

Physican report :  Normal  Abnormal

Birth weight:

_________ grams

_________ lbs/oz

Birth length:

_________  cm

_________ in

Repeat head circumference: _______ cm _______ in  < 24hrs  24-35hrs  36-48hrs  > 48hrs Physican report :  Normal  Abnormal

Admitted to Neonatal Intensive Care Unit:  No  Yes, If yes, reason ______________________

Microcephaly (head circumference <3%ile):  No  Yes

Seizures:  No  Yes

Neurologic exam: check all that apply  Not performed  Unknown

 Normal  Hypertonia/Spasticity  Hyperreflexia  Irritability

 Tremors  Other Neurologic abnormalities (please describe below)

Splenomegaly by physical exam:  No  Yes  Unknown

(please describe)

Hepatomegaly by physical exam:  No  Yes  Unknown

(please describe)

Skin rash by physical exam:  No  Yes  Unknown

(please describe)

Other abnormalities identified: (please provide clinical description from medical records and include chromosomal abnormalities and syndromes); please check all that apply

 Microphthalmia  Absent red reflex  Excessive and redundant scalp skin  Arthrogryposis (congenital joint contractures)  Congenital Talipes Equinovarus (clubfoot)

 Other abnormalities (please describe below)

Neonate Imaging and Diagnostics

Hearing screening : (date:____/_____/_____)  Pass  Fail or referred  Not performed

(please describe below)

Retinal exam (with dilation):  Not Performed  Unknown

If performed: (date: _____/_____/_____) please check all that apply:

 Microphthalmia  Chorioretinitis  Macular pallor  Other retinal abnormalities (please describe below)

Imaging study:  Cranial ultrasound (date: _____/_____/_____)  MRI (date: _____/_____/_____)

 CT (date: _____/_____/_____)  Not Performed

Findings: check all that apply

 Microcephaly  Cerebral (brain) atrophy  Intracranial calcification  Ventricular enlargement  Lissencephaly  Pachygyria  Hydranencephaly  Porencephaly  Abnormality of corpus callosum  Other abnormalities (please describe below)

Imaging study:  Cranial ultrasound (date: _____/_____/_____)  MRI (date: _____/_____/_____)

 CT (date: _____/_____/_____)  Not Performed

Findings: check all that apply

 Microcephaly  Cerebral (brain) atrophy  Intracranial calcification  Ventricular enlargement  Lissencephaly  Pachygyria  Hydranencephaly  Porencephaly  Abnormality of corpus callosum  Other abnormalities (please describe below)

Imaging study:  Cranial ultrasound (date: _____/_____/_____)  MRI (date: _____/_____/_____)

 CT (date: _____/_____/_____)  Not Performed

Findings: check all that apply

 Microcephaly  Cerebral (brain) atrophy  Intracranial calcification  Ventricular enlargement  Lissencephaly  Pachygyria  Hydranencephaly  Porencephaly  Abnormality of corpus callosum

 Other abnormalities (please describe below)

Was a lumbar puncture performed:  Yes  No  Unknown (date: _____/_____/_____)

Congenital Infection Testing: if performed, please specify test (i.e. PCR, IgG, IgM)
	Toxoplasmosis	Cytomegalovirus	Herpes Simplex	Rubella	Other
Positive
Negative
Not Done
Date

Other tests/results/diagnosis (include dates):

Provider Information

Neonatal Provider name:  Dr.  PA  RN  Mr.  Ms. ______________________________________

Phone: _______________ Email: ________________________ Date of form completion _____/_____/____

Pediatric Provider name:  Dr.  PA  RN  Mr.  Ms. ______________________________________

Phone: ____________________________________ Email: ______________________________________

Name of person completing form: (if different from provider) _____________________________________

Hospital/facility:________________________________Phone:_______________________________________

Name of Infant Pediatrician: _________________________________________________________________

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:

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)