Infant Health Follow-Up Form

US Zika Pregnancy Registry

ATT_D_USZPR_Infant_Follow_Up_Revised 21SEP2016

Infant Health Follow-Up Form

OMB: 0920-1143

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Infant’s State/Territory ID __________________ Registry ID __________

Mother’s State/Territory ID ________________

Approved

OMB No. 0920-1101

Exp. 08/31/2016


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

Infant Follow-Up 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

Infant follow up: 2 months 6 months 12 months ___ months


IFU.1. State/Territory reporting _________________ IFU.2. Date of infant examination _____/_____/____

IFU.3. Infant’s State/Territory ID _________________

IFU.4. Mother’s State/Territory ID ____________________

IFU.5. DOB:

____/_____/_____

IFU.6. Sex: Male Female

Ambiguous/undetermined

IFU.7. Infant Death: No Yes IFU.8. If yes, cause of death __________________________

IFU.9. If yes, Date _____/_____/____ or Age at death ________ Unknown

IFU.10. Weight:

_______grams or ____ lbs_____ oz

IFU.11. Length:

_______ cm or _______ in

IFU.12. Head circumference:

_______ cm or _______ in

IFU.13. Infant findings for corrected age at examination: (For infants born preterm, please account for corrected age: chronological age minus weeks born before 40 weeks’ gestation)


Check all that apply

Normal Microcephaly (head circumference <3%ile)

Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)

Anencephaly/ acrania Encephalocele Spina bifida

Holoprosencephaly/arhinencephaly Microphthalmia/Anophthalmia

Hypertonia/Spasticity Hyperreflexia Irritability Tremors

Splenomegaly Hepatomegaly Skin rash

Swallowing/feeding difficulties

Arthrogryposis (congenital joint contractures)

Congenital talipes equinovarus (clubfoot)

Congenital hip dislocation/developmental dysplasia of the hip

Other abnormalities

IFU.14. Please list other abnormal findings:




IFU.15. Development assessment for corrected age at examination: (For infants born preterm, please account for corrected age: chronological age minus weeks born before 40 weeks’ gestation)

Normal Abnormal Unknown


IFU.16. If developmental delay, in what area? Please check all that apply

Gross motor Fine motor Cognitive, linguistic and communication Socio-Emotional

Special Studies Since Last Follow-up

IFU.17. Imaging study: Cranial ultrasound MRI CT Other _____________

Not Performed Unknown

IFU.18. Date: _____/_____/_____


IFU.19. Findings: check all that apply Normal

Microcephaly Intracranial calcifications Cerebral/cortical atrophy

Abnormal cortical gyral patterns (lissencephaly, pachygyria, agyria, microgyria, polymicrogyria, schizencephaly)

Corpus callosum abnormalities Cerebellar abnormalities Porencephaly

Hydranencephaly Moderate or severe ventriculomegaly/hydrocephaly

Fetal Brain Disruption Sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae) Other major brain abnormalities

Encephalocele Holoprosencephaly/ arhinencephaly

Other abnormalities

IFU.20. Please describe below




IFU.21. Imaging study: Cranial ultrasound MRI CT Other ______________

Not Performed Unknown

IFU.22. Date: _____/_____/_____


IFU.23. Findings: check all that apply Normal

Microcephaly Intracranial calcifications Cerebral/cortical atrophy

Abnormal cortical gyral patterns (lissencephaly, pachygyria, agyria, microgyria, polymicrogyria, schizencephaly)

Corpus callosum abnormalities Cerebellar abnormalities Porencephaly

Hydranencephaly Moderate or severe ventriculomegaly/hydrocephaly

Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae) Other major brain abnormalities

Encephalocele Holoprosencephaly/ arhinencephaly

Other abnormalities

IFU.24. (please describe below)



IFU.25. Hearing screening or re-screening: Not performed Performed Unknown

IFU.26. If performed: Date: ____/____/____ IFU.27. Pass Fail or referred,

IFU.28. Please describe


IFU.29. Audiological evaluation: Not performed Performed Unknown

IFU.30. If performed: Date: ____/____/____ IFU.31. Normal Abnormal,

IFU.32. Please describe



IFU.33. Retinal exam (with dilation): Not Performed Performed Unknown

IFU.34. If performed: Date: _____/_____/_____

IFU.35. Findings: Check all that apply:

Microphthalmia/anophthalmia Coloboma Cataract Intraocular calcifications

Chorioretinal atrophy, scarring, macular pallor, gross pigmentary mottling, or retinal hemorrhage, excluding retinopathy of prematurity Other retinal abnormalities

Optic nerve atrophy, pallor Other optic nerve abnormalities

IFU.36. Please describe



IFU.37. Other abnormal tests/results/diagnosis (include dates): No Yes

IFU.38. Date: _____/_____/_____

IFU.39. Please describe



Health Department Information

IFU.40. Name of person completing form: _______________________________________________________

IFU.41. Phone: _______________ IFU.40. Email: ________________________

IFU.42. Date of form completion _____/_____/____

Internal use only

Date entered____/_____/_____

Data Entry POC Initials: ________

Data Entry Notes:

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)


Version 8/31/2016

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File TitleA TULANE UNIVERSITY HEALTH SCIENCES CENTER RESEARCH STUDY
AuthorCDC User
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File Created2021-01-23

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