Laboratory Results Form

US Zika Pregnancy Registry

ATT_E_USZPR_Laboratory_Results_Revised 21SEP2016

Laboratory Results Form

OMB: 0920-1143

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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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGupta, Priya M. (CDC/ONDIEH/NCCDPHP) (CTR)
File Modified0000-00-00
File Created2021-01-23

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