Pregnancy and Zika Virus Disease Surveillance Form - Inf

CDC Emergency Operations Center Zika Related Clinical Inquiries and Surveillance

Att. G -- Infant Health Follow-Up Form 31MAR2016

Infant Health Follow-Up Form

OMB: 0920-1101

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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)



File Typeapplication/msword
File TitleA TULANE UNIVERSITY HEALTH SCIENCES CENTER RESEARCH STUDY
Authormsl1
Last Modified ByZirger, Jeffrey (CDC/OD/OADS)
File Modified2016-03-31
File Created2016-03-29

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