Pregnancy and Zika Virus Disease Surveillance Form - Neo

CDC Emergency Operations Center Zika Related Clinical Inquiries and Surveillance

Att. F -- Assessment at Delivery Form

Assessment at Delivery Form

OMB: 0920-1101

Document [pdf]
Download: pdf | pdf
Form Approved
OMB Control No.: 0920-XXXX
Expiration date: XX/XX/XXXX

Pregnancy and Zika virus disease surveillance 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 by fax to (970) 266-3568 or email XXXX@cdc.gov

Neonate assessment at delivery
Infant’s name: ____________________________

DOB: _____/_____/_____

State of residence: __________________________

County of residence:_________________________

Sex:  Male

 Female

Gestational age at delivery: ______ weeks

Apgar score: 1 min ____ / 5 min ____
Birth weight:
 kg  lbs/oz

Infant temp at delivery: _______ oF Cord blood pH ___________


Length:
cm  in

Head circumference:
 cm  in

Delivery type:  Vaginal  Forceps/suction  Caesarean section
Microcephaly  No

 Yes

Neurologic abnormalities:  No
(please describe)

Splenomegaly:  No

Skin rash:  No

Maternal temp at delivery: ______°F

Admitted to NICU:
 Yes

 Yes

Dysmorphic features:  No  Yes
(please describe)

 Yes (please describe)

 Yes (please describe)

 No

Hepatomegaly:  No

 Yes (please describe)

Other abnormalities identified:  No  Yes
(please provide clinical description from medical
records)

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Form Approved
OMB Control No.: 0920-XXXX
Expiration date: XX/XX/XXXX

Pregnancy and Zika virus disease surveillance 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 by fax to (970) 266-3568 or email XXXX@cdc.gov

Neonate Imaging and Diagnostics
Hearing evaluation performed:  Normal
 Abnormal (please describe)  Not Done

Ophthalmologic evaluation performed:  Normal
 Abnormal (please describe)  Not Done

Placental exam (pathologist):  No  Yes
(please describe)

Imaging study result:  N/A  Normal 
Abnormal
(please list type, date, and describe)

Lumbar puncture performed:  No  Yes
If yes,  Normal  Abnormal (please describe)

TORCH testing result:  Not Done  Negative 
Positive (if positive, please specify pathogen and test
(e.g., PCR, IgG, IgM))

Other tests/results:

Provider Information
Provider name:  Dr.  PA  RN  Mr.  Ms.
___________________________________________

Phone: ________________________________
Email: _________________________________

Name of person completing form: (if different from provider) Hospital/facility: ______________________
_________________________________________
_______________________________________
_________________________________________
Phone:_________________________________
FOR INTERNAL CDC USE ONLY
Mother ID:

State 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-XXXX)

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File Typeapplication/pdf
File TitleMicrosoft Word - Zika virus pregnancy register_20160203_v1 0
Authorllj3
File Modified2016-02-09
File Created2016-02-09

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