Supplemental Maternal Prenatal Imaging and Diagnostics F

U .S. Zika Pregnancy Registry and Birth Defects Surveillance — Integrated Supplemental Maternal Prenatal Imaging and Diagnostics 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 at: 770-488-7100
MHH.1. State/Territory ID: ________________________________		MHH.3. State/Territory reporting: ________________ MHH.4. County reporting: ______________________
SIF.79. Date(s) of ultrasound(s): ___/___/___  SIF.80. Check if date approximated SIF.81. If date not known, Gestational age ____________ (weeks, days)	SIF.82. Overall fetal ultrasound results:  Normal  Abnormal
	SIF.83.  Reported by patient/healthcare provider  Ultrasound report
	SIF.84. Head circumference _______cm SIF.85.  Normal  Abnormal (by physician report)
	SIF.86. Biparietal diameter (BPD) ______cm SIF.87. Femur length (FL) _____cm SIF.88. Abdominal circumference (AC) _____cm
	SIF.89.  Symmetric intrauterine growth restriction (IUGR)  Asymmetric IUGR (HC>AC or HC>FL)
	SIF.90. Microcephaly		 No  Yes		SIF.91. Intracranial calcifications		 No  Yes
	SIF.92. Cerebral / cortical atrophy		 No  Yes		SIF.93. Abnormal cortical gyral patterns (e.g., polymicrogyria, lissencephaly, pachygyria, schizencephaly, gray matter heterotopia)	 No  Yes
	SIF.94. Corpus callosum abnormalities		 No  Yes		SIF.95. Cerebellar abnormalities	 No  Yes
	SIF.96. Porencephaly		 No  Yes		SIF.97. Hydranencephaly	 No  Yes
	SIF.98. Moderate or severe ventriculomegaly/ hydrocephaly		 No  Yes		SIF.99. Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)	 No  Yes
	SIF.100. Other major brain abnormalities		 No  Yes		SIF.101. Anencephaly / acrania	 No  Yes
	SIF.102. Encephalocele		 No  Yes		SIF.103. Spina bifida	 No  Yes
	SIF.104. Holoprosencephaly/ arhinencephaly		 No  Yes		SIF.105. Structural eye abnormalities/dysplasia	 No  Yes
	SIF.106. Arthrogryposis		 No  Yes		SIF.107. Clubfoot	 No  Yes
	SIF.108. Hydrops		 No  Yes		SIF.109. Ascites	 No  Yes
	SIF.110. Other		 No  Yes If yes, describe:
SIF.111. Description of abnormal ultrasound findings:
SIF.112. Date(s) of Ultrasound(s): ____/____/____  SIF.113. check if date approximated SIF.114. if date not known, gestational age ____________ (weeks, days)	SIF.115. Overall fetal ultrasound results:  Normal  Abnormal
	SIF.116.  Reported by patient/healthcare provider SIF.117.  Ultrasound report
	SIF.118. Head Circumference _______cm SIF.119.  Normal  Abnormal (by physician report)
	SIF.120. Biparietal diameter (BPD) ______cm SIF.121. Femur length (FL) _____cm SIF.122. Abdominal circumference (AC) _____cm
	SIF.123.  Symmetric IUGR  Asymmetric IUGR (HC>AC or HC>FL)
	SIF.124. Microcephaly		 No  Yes	SIF.125. Intracranial calcifications		 No  Yes
	SIF.126. Cerebral / cortical atrophy		 No  Yes	SIF.127. Abnormal cortical gyral patterns (e.g., polymicrogyria, lissencephaly, pachygyria, schizencephaly, gray matter heterotopia)		 No  Yes
	SIF.128. Corpus callosum abnormalities		 No  Yes	SIF.129. Cerebellar abnormalities		 No  Yes
	SIF.130. Porencephaly		 No  Yes	SIF.131. Hydranencephaly		 No  Yes
	SIF.132. Moderate or severe ventriculomegaly/ hydrocephaly		 No  Yes	SIF.133. Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)		 No  Yes
	SIF.134. Other major brain abnormalities		 No  Yes	SIF.135. Anencephaly / acrania		 No  Yes
	SIF.136. Encephalocele		 No  Yes	SIF.137. Spina bifida		 No  Yes
	SIF.138. Holoprosencephaly/ arhinencephaly		 No  Yes	SIF.139. Structural eye abnormalities/dysplasia		 No  Yes
	SIF.140. Arthrogryposis		 No  Yes	SIF.141. Clubfoot		 No  Yes
	SIF.142. Hydrops		 No  Yes	SIF.143. Ascites		 No  Yes
	SIF.144. Other		 No  Yes If yes, describe:
SIF.145. Description of abnormal ultrasound findings:
Health Department Information
SIF.230. Name of person completing form: _____________________________________________________ SIF.231. Phone: _______________ SIF.232. Email: _________________________ SIF.233. Date form completed ___/____/____
FOR INTERNAL CDC USE ONLY Mother ID: State/Territory ID: Zika T ID:
R number: _____________ Mother infection type:  Confirmed  Probable  Possible  Exclude
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