Neonate Assessment at Delivery Form

US Zika Pregnancy Registry

ATT_C_USZPR_Neonate_Assessment_At_Delivery_Revised 21SEP2016

Neonate Assessment at Delivery Form

OMB: 0920-1143

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

Neonate Assessment 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


NAD.1. Infant’s State/Territory ID ________________

NAD.2. Mother’s State/Territory ID ________________

NAD.3. DOB:

_____/_____/______

Live birth

Stillbirth ≥20 weeks

NAD.4. Sex:

Male Female

Ambiguous/undetermined

NAD.5. Gestational age at delivery:

______ weeks ______ days

NAD.6. Based on: (check all that apply)

LMP ___/___/___ 1st trimester ultrasound 2nd trimester ultrasound 3rd trimester ultrasound Other_______________

NAD.7. Maternal age at delivery ____ years

NAD.8. State/Territory reporting: _______________

NAD.9. County reporting: __________________

NAD.10. Delivery type:

Vaginal Caesarean section

NAD.11. Delivery complication: No Yes

NAD.12. If yes, please describe: _______________________________________

NAD.13. Arterial cord blood pH (if performed): _________


NAD.14. Venous cord blood pH (if performed): _________

NAD.15. Placental exam (based on path report): No Yes

NAD.16. If yes, Normal Abruption Inflammation Other abnormality (please describe)



NAD.17. Apgar score:

1 min _______ / 5 min ________

NAD.18. Infant temp (if abnormal): _______ oF or ______ oC

Physical Examination (record earliest measurements taken)

NAD.19. Birth head circumference:

_______ cm ________ in

NAD.20. Molding present

NAD.21. Physican report: Normal Abnormal

NAD.22. HC percentile:_______

NAD.23. Birth weight:

_________ grams

_________ lbs/oz

NAD.24. Birth weight percentile: ________

NAD.25. Birth length:

_________ cm

_________ in

NAD.26. Birth length percentile:________

NAD.27. Repeat head circumference: _______ cm _______ in

NAD.28. Date performed ___ /____ /____ or

Age _______ day(s)

NAD.29. Physican report: Normal Abnormal

NAD.30. HC percentile:________

NAD.31. Admitted to Neonatal Intensive Care Unit:

No Yes If yes, reason: ____________________________________________

NAD.32. Neonatal death: No Yes

NAD.33. Date __/__/____ or Age at death_____ days

NAD.34. Cause of death: _______________________

NAD.35. Microcephaly (head circumference <3%ile): No Yes

NAD.36. Seizures: No Yes

NAD.37. Neurologic exam: (check all that apply)
Not performed Unknown Normal Hypertonia/Spasticity Hyperreflexia Irritability

Tremors Other neurologic abnormalities NAD.38. (please describe below)



NAD.39. Splenomegaly by physical exam:
No Yes Unknown
NAD.
40. (please describe)



NAD.41. Hepatomegaly by physical exam:
No Yes Unknown
NAD.
42. (please describe)




NAD.43. Skin rash by physical exam:

No Yes Unknown
NAD.
44. (please describe)


NAD.45. Other abnormalities identified: please check all that apply

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

Encephalocele Anencephaly/ Acrania Spina bifida Holoprosencephaly/arhinencephaly

Microphthalmia/Anophthalmia Arthrogryposis (congenital joint contractures)

Congenital Talipes Equinovarus (clubfoot) Congenital hip dislocation/developmental dysplasia of the hip

Other abnormalities

NAD.46. (please describe below)




Neonate Imaging and Diagnostics

NAD.47. Hearing screening : (date:____/_____/_____) or Age _______ day(s)

NAD.48. Pass Fail Inconclusive/Needs retest Not performed

NAD.49. Please describe


NAD.50. Audiological evaluation: Not performed Auditory brainstem response (ABR) test performed

Otoacoustic emisions (OAE) test performed Acoustic stapedius reflex (ASR) test performed

Unknown

NAD.51. If performed: Date: ___/___/___ NAD.52. Normal Abnormal,

NAD.53. Please describe


NAD.54. Retinal exam (with dilation): Not Performed Performed Unknown

NAD.55. If performed: (date: _____/_____/_____) or Age _______ day(s)

NAD.56. please check all that apply: Normal

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

NAD.57. (please describe below)




NAD.58. Imaging study: Cranial ultrasound MRI CT Not Performed

NAD.59. (date: _____/_____/_____) or Age _______ day(s)
NAD.60. Findings: check all that apply Normal

Microcephaly Intracranial calcification 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

NAD.61. (please describe below)




NAD.62. Imaging study: Cranial ultrasound MRI CT Not Performed

NAD.63. (date: _____/_____/_____) or Age _______ day(s)
NAD.64. Findings: check all that apply Normal

Microcephaly Intracranial calcification 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

NAD.65. (please describe below)





NAD.66. Imaging study: Cranial ultrasound MRI CT Not Performed

NAD.67. (date: _____/_____/_____) or Age _______ day(s)

NAD.68. Findings: check all that apply Normal

Microcephaly Intracranial calcification 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

NAD.69. (please describe below)




NAD.70. Was a lumbar puncture performed: Yes No Unknown NAD.71. (date: _____/_____/_____) or Age _______ day(s)




Postnatal Infection Testing (includes urine culture for CMV)

NAD.72.

Toxoplasmosis infection:

No Yes Unknown

NAD.73.

Cytomegalovirus infection:

No Yes Unknown

NAD.74.

Herpes Simplex infection:

No Yes Unknown

NAD.75.

Rubella infection:

No Yes Unknown

NAD.76.

Lymphocytic choriomeningitis virus infection:

No Yes Unknown

NAD.77.

Syphilis infection:

No Yes Unknown

NAD.78. If yes for any postnatal infection testing, please describe results:




Postnatal (Infant) Cytogenetic Testing

NAD.79. Cytogenetic Test

Karyotype

FISH

CGH microarray

Other, specify ____________________


NAD.80. Date:

_____/_____/______

NAD.81. Infant Age: _____ months


NAD.82. Specimen

Cord blood

Peripheral blood

Tissue

Other, specify ____________________

NAD.83. Test Result

Normal

Abnormal

Unknown


NAD.84. Description of cytogenetic test findings (verbatim):



NAD.85. Other tests/results/diagnosis (include dates):

Birth Defects Diagnosed or Suspected (Include Chromosomal Abnormalities and Syndromes)

Diagnostic Code

Certainty

Verbatim Description


Definite

Possible/Probable



Definite

Possible/Probable



Definite

Possible/Probable



Definite

Possible/Probable



Definite

Possible/Probable



Definite

Possible/Probable


Health Department Information

NAD.86. Name of person completing form: ________________________________________________

NAD.87. Phone: _______________

NAD.88. Email: ________________________ NAD.89. Date of form completion _____/_____/____

FOR INTERNAL CDC USE ONLY

Mother ID: State/territory ID:


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)




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