Infant Health Follow-Up Form - 2 year

Infant/Child’s State/Territory ID __________________ Registry ID __________ Mother’s State/Territory ID ________________

Approved OMB No. 0920-1143 Exp. 11/30/2019

U.S. Zika Pregnancy Registry

Infant/Child 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

Infant/Child follow up:  2 months  6 months  12 months  18 months  24 months  ___ months

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

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

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

IFU.5. DOB:

______________

IFU.6. Sex:  Male  Female

 Ambiguous/undetermined

IFU.7. Infant/Child 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/Child 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

	Developmental Milestones†
	Gross motor	Fine motor	Cognitive, Linguistic and communication	Social-Emotional
2 months of age	*Lift head	*Follow to midline	*Vocalize	*Smile responsively
4 months of age	*Sit – head steady	*Grasp rattle	*Laugh	*Regard own hand
6 months of age	*Roll over	*Reach	*Turn to rattling sound	*Work for toy (out of reach)
9 months of age	*Stand holding on	*Pass cube (transfer)	*Single syllables	*Feed self
12 months of age	*Pull to stand	*Bang 2 cubes held in hands	*Imitate vocalization/sounds *Babbling	*Pointing to indicate object of interest *Play pat-a-cake
†More than 90% of children pass this item at indicated age. In infants born preterm, please account for corrected age [chronological age (in weeks) minus weeks born before 40 weeks gestation] when considering development. Source: Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.

Health Department Information

IFU.40. Name of person completing form: _______________________________________________________

IFU.41. Phone: _______________ IFU.42. Email: ________________________

IFU.43. 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 (0920-1143)

10/26/2017