Pregnant Woman Eligibility Screening Form

ZEN Colombia: Pregnant Woman Eligibility

Name of Person Completing the Form: _______________________________________________

Today’s date: _____/______/________

DD MMM YYYY

Clinic Information

Clinic name: _________________________________________

City: □ Barranquilla □ Cali

Patient Information

Last name: _________________________________________

First name: _________________________________________

Eligibility Criteria

Is the patient in the first trimester of pregnancy (≤14+6 weeks)?	□ Yes □ No
Is the pregnancy neither an ectopic nor a molar pregnancy?	□ Yes □ No
Is the patient planning to have prenatal care at a participating clinic?	□ Yes □ No
Is the patient 18 years of age or older?	□ Yes □ No
Does the patient speak Spanish?	□ Yes □ No

Exclusion Criteria

Is the patient incarcerated?	□ Yes □ No
Is the patient unable to physically or psychologically participate based on clinical judgement?	□ Yes □ No

Eligibility Determination

The patient is eligible for the study. (All answers to eligibility criteria questions are Yes AND all answers to exclusion criteria are No.)

□ Yes □ No

Informed Consent

Did the patient receive and provide informed consent for participation and provide permission for her baby to participate in the study after birth? □ Yes □ No

Zika Prevention Kit Distribution

Did you give the patient a Zika Prevention Kit before she left?

□ Yes, she took it □ Offered it to her, but she didn’t want/take it □ Did not offer

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