Pregnancy and Zika Virus Disease Surveillance Form - Inf

Infant’s State/Territory ID____________ Mother’s State/Territory ID ______________ Approved

OMB No. 0920-1101

Exp. 08/31/2016

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 sending an encrypted email to ZIKApregnancy@cdc.gov or by fax to the secure number: 404-718-2200. Pregnancy & Birth Defects phone number: 770-488-7100
Infant follow up:  2 months  6 months  12 months
Infant’s name: _____________________________________________________ Last First MI						Date of infant examination _____/_____/____
Infant’s State/Territory ID __________________	Mother’s State/Territory ID ____________________		DOB: _____/_____/_____		Sex:  Male  Female  Ambiguous/undetermined
Infant Death:  No  Yes, date _____/_____/____  Unknown
Weight: _________ grams _________  lbs/oz		Length: _________  cm __________  in		Head circumference __________  cm __________  in
Infant 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  Microcephaly (head circumference <3%ile)  Excessive and redundant scalp skin  Arthrogryposis (congenital joint contractures)  Congenital Talipes Equinovarus (clubfoot)  Hypertonia/Spasticity  Hyperreflexia  Irritability  Tremors  Splenomegaly  Hepatomegaly  Skin rash  Microphthalmia  Absent red reflex  Excessive and redundant scalp skin  Swallowing/feeding difficulties  Congenital Talipes Equinovarus (clubfoot)  Arthrogryposis (congenital joint contractures) Please list other abnormal findings:
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 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
Imaging study:  Cranial ultrasound (date: _____/_____/_____)  MRI (date: _____/_____/_____)  CT (date: _____/_____/_____)  Other ____________________  Not Performed Findings: check all that apply  Microcephaly  Cerebral (brain) atrophy  Intracranial calcification  Ventricular enlargement  Lissencephaly  Pachygyria  Hydranencephaly  Porencephaly  Abnormality of corpus callosum  Other abnormalities (please describe below)
Imaging study:  Cranial ultrasound (date: _____/_____/_____)  MRI (date: _____/_____/_____)  CT (date: _____/_____/_____)  Other ____________________  Not Performed Findings: check all that apply  Microcephaly  Cerebral (brain) atrophy  Intracranial calcification  Ventricular enlargement  Lissencephaly  Pachygyria  Hydranencephaly  Porencephaly  Abnormality of corpus callosum  Other abnormalities (please describe below)
Hearing screening or re-screening:  Not performed  Unknown If performed: (date:____/____/____)  Pass  Fail or referred, please describe
Audiological evaluation:  Not performed  Unknown If performed: (date:____/____/____)  Normal  Abnormal, please describe
Retinal exam (with dilation):  Not Performed  Unknown If performed: please check all that apply: (date: _____/_____/_____)  Microphthalmia  Chorioretinitis  Macular pallor  Other retinal abnormalities(please describe below)
Other abnormal tests/results/diagnosis (include dates):  No  Yes (date: _____/_____/_____) please describe
Provider Information
Pediatric Provider name:  Dr.  PA  RN  Mr.  Ms. ______________________________________ Phone: _______________ Email: ________________________ Date of form completion _____/_____/____
Name of person completing form: (if different from provider) _____________________________________ Hospital/facility:________________________________ Phone: _____________________________________ Email: ________________________________________ Date of form completion _____/_____/____
Health Department Information
Name of person completing form: _____________________________________________________________ Phone: _______________ Email: ________________________ 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)