Laboratory Results Form

Approved

OMB No. 0920-1101

Exp. 08/31/2016

U .S. Zika Pregnancy Registry and Birth Defects Surveillance — Integrated

Laboratory Results 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 via SAMS or secure FTP—request access from [email protected]

The form can also be sent by encrypted email to this address or by secure fax to 404-718-1013 or 404-718-2200

Contact Pregnancy & Birth Defects Task Force phone number: 770-488-7100

LAB.1. Mother’s State/Territory Reporting: ___________ LAB.2. Mother’s State/territory ID: ____________________ LAB.3. Mother’s ArboNET ID: _________________________					LAB.4. Infant’s State/Territory Reporting (if different from mother): _____________________________ LAB.5. Infant’s State/Territory ID: _______________________ LAB.6. Infant’s ArboNET ID: _____________________________
LAB.7. Specimen Type  Maternal serum  Maternal urine  Infant serum  Infant urine  Maternal whole blood	 Infant whole blood  Infant CSF  Amniotic fluid  Cord serum  Fixed cord tissue  Frozen cord tissue		 Fixed placenta  Frozen placenta  Brain tissue  Membrane tissue  Heart tissue  Kidney tissue			 Liver tissue  Lung tissue  Ocular tissue  Skeletal tissue  Spleen tissue  Bone marrow	 Nonspecific fetal tissue  Other maternal specimen*  Other infant specimen*  Other fetal specimen *
*If Other specimen type, please specify __________________________________________________________________________
LAB.8. Location of testing  Commercial Lab  State PHL  CDC  Other: _______________________________				LAB.9. Specimen collection date: _____/_____/______
LAB.10. Zika IgM performed?  No  Yes  Pending				LAB.11. Zika IgM result:  Positive  Negative  Equivocal  Inconclusive
LAB.12. Dengue IgM performed?  No  Yes				LAB.13. Dengue IgM result:  Positive  Negative  Equivocal  Inconclusive
LAB.14. Zika RT-PCR performed?  No  Yes				LAB.15. Zika RT-PCR result:  Positive  Negative  Equivocal  Indeterminate
LAB.16. Dengue RT-PCR performed?  No  Yes				LAB.17. Dengue RT-PCR result:  Positive  Negative  Equivocal  Indeterminate
LAB.18. PRNT performed?  No  Yes				LAB.19. Zika PRNT result: __________________________________ LAB.20. Dengue PRNT result:________________________________
Pathology Results
LAB.21. Zika immunohistochemistry (IHC) staining performed?  No  Yes				LAB.22. Zika Immunohistochemistry (IHC) staining result:  Positive  Negative
LAB.23. Histopathology evaluation performed?  No  Yes				LAB.24. Histopathology evaluation results:
LAB.25. Other test performed? (including autopsy)  No  Yes				LAB.26. Other test results:
Findings (verbatim)
Internal use only
Record ID _________________ Date entered____/_____/_____ Data Entry POC Name: _________________________		Data Entry Notes:_________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Version 8/31/2016