Zika Virus Disease Enhanced Surveillance – Postnatally a

Form Approved

OMB Control No. 0920-XXXX

Exp. date: XX/XX/XXXX

Attachment 4: Zika Virus Disease Enhanced Surveillance – Postnatally acquired Zika virus disease among children aged <18 years

Demographic Information
Case ID (ArboNET):_____________________ Control for Case ID:____________________ State of residence:_____________________ County of residence:___________________ Age: ______  Years  Months  Days Sex:  Male  Female Pregnant:  Yes  No  Unknown Est Date Delivery: ____/____/____ OR Last Menstrual Period: ____/____/____ Race (Select all appropriate):  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White  Other  Unknown Ethnicity:  Hispanic or Latino  Not Hispanic or Latino  Unknown Co-morbidities:  Yes  No  Unknown Describe:_______________________________________________________ Imported From:  Not Imported  Acquired Out of State  Acquired Out of Country  Unknown Country of Origin:________________________________ Travel dates:____________________________ State of Origin:__________________________________ Travel dates: ____________________________ Other possible exposures:  Sexual  Breastfeeding  Blood products  Organs
Clinical Information
Illness onset date: _____/_____/_____
Clinical syndrome:  Febrile illness  Encephalitis/meningoencephalitis  Meningitis  Acute flaccid paralysis  Guillain-Barré syndrome  Other neuroinvasive presentation  Other clinical______________________
Case Status (ArboNET):  Confirmed  Probable
Fever	 Yes  No  Unk  Subjective  Measured (Max temperature: __________)
Chills/Rigors	 Yes  No  Unk
Rash	 Yes  No  Unk Type:  Maculopapular  Petechial  Purpuric  Other:____________________________________________ Pruritic:  Yes  No  Unk Distribution:­­­­­­­_______________________________________________
Headache	 Yes  No  Unk
Retro-orbital pain	 Yes  No  Unk
Conjunctivitis	 Yes  No  Unk
Oral ulcers	 Yes  No  Unk
Nausea/Vomiting	 Yes  No  Unk
Diarrhea	 Yes  No  Unk
Arthralgia	 Yes  No  Unk
Arthritis	 Yes  No  Unk
Myalgia	 Yes  No  Unk
Paresis/Paralysis	 Yes  No  Unk
Stiff Neck	 Yes  No  Unk
Ataxia	 Yes  No  Unk
Altered mental status	 Yes  No  Unk
Seizures	 Yes  No  Unk
Clinical Information (continued)
Sore throat	 Yes  No  Unk
Cough	 Yes  No  Unk
Lymphadenopathy	 Yes  No  Unk
Paresthesia	 Yes  No  Unk
Abdominal pain	 Yes  No  Unk
Edema	 Yes  No  Unk Specify:__________________________________________________
CBC performed	 Yes  No  Unk Leukopenia  Yes (<4,500) Nadir:________  No  Unk Thrombocytopenia  Yes (<150,000) Nadir:_______  No  Unk
LP performed	 Yes  No  Unk CSF Pleocytosis  Yes  No  Unk (WBC count >=5)
Other	 Yes  No  Unk Specify:__________________________________________________
Outcomes
Emergency department	 Yes  No  Unk
Hospitalized	 Yes  No  Unk	Admission Date: _____/_____/_____ Discharge Date:_____/_____/_____ OR Days hospitalized:______________
Died	 Yes  No  Unk	Date of Death:_____/_____/_____
Zika Virus Test Results		Dengue Virus Test Results
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial		Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial		Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial		Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial		Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial

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