Neonate Assessment at Delivery Form

U .S. Zika Pregnancy Registry and Birth Defects Surveillance — Integrated

Neonate Assessment 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 ZIKApregnancy@cdc.gov

The form can also be sent by encrypted email to this address or by secure fax to 404-718-1013 or 404-718-2200

Contact Pregnancy & Birth Defects Task Force phone number: 770-488-7100

NAD.1. Infant’s State/Territory ID ________________

NAD.2. Mother’s State/Territory ID ________________

NAD.3. DOB:

_____/_____/______

Live birth

Stillbirth ≥20 weeks

NAD.4. Sex:

 Male  Female

 Ambiguous/undetermined

NAD.5. Gestational age at delivery:

______ weeks ______ days

NAD.6. Based on: (check all that apply)

 LMP ___/___/___  1^st trimester ultrasound  2^nd trimester ultrasound  3^rd trimester ultrasound  Other_______________

NAD.7. Maternal age at delivery ____ years

NAD.8. State/Territory reporting: _______________

NAD.9. County reporting: __________________

NAD.10. Delivery type:

 Vaginal  Caesarean section

NAD.11. Delivery complication:  No  Yes

NAD.12. If yes, please describe: _______________________________________

NAD.13. Arterial cord blood pH (if performed): _________

NAD.14. Venous cord blood pH (if performed): _________

NAD.15. Placental exam (based on path report):  No  Yes

NAD.16. If yes,  Normal  Abruption  Inflammation  Other abnormality (please describe)

NAD.17. Apgar score:

1 min _______ / 5 min ________

NAD.18. Infant temp (if abnormal): _______ ^oF or ______ ^oC

Physical Examination (record earliest measurements taken)

NAD.19. Birth head circumference:

_______ cm ________ in

NAD.20.  Molding present

NAD.21. Physican report:  Normal  Abnormal

NAD.22. HC percentile:_______

NAD.23. Birth weight:

_________ grams

_________ lbs/oz

NAD.24. Birth weight percentile: ________

NAD.25. Birth length:

_________  cm

_________  in

NAD.26. Birth length percentile:________

NAD.27. Repeat head circumference: _______ cm _______ in

NAD.28. Date performed ___ /____ /____ or

Age _______ day(s)

NAD.29. Physican report:  Normal  Abnormal

NAD.30. HC percentile:________

NAD.31. Admitted to Neonatal Intensive Care Unit:

 No  Yes If yes, reason: ____________________________________________

NAD.32. Neonatal death:  No  Yes

NAD.33. Date __/__/____ or Age at death_____ days

NAD.34. Cause of death: _______________________

NAD.35. Microcephaly (head circumference <3%ile):  No  Yes

NAD.36. Seizures:  No  Yes

NAD.37. Neurologic exam: (check all that apply)
 Not performed  Unknown  Normal  Hypertonia/Spasticity  Hyperreflexia  Irritability

 Tremors  Other neurologic abnormalities NAD.38. (please describe below)

NAD.39. Splenomegaly by physical exam:
 No  Yes  Unknown
NAD.40. (please describe)

NAD.41. Hepatomegaly by physical exam:
 No  Yes  Unknown
NAD.42. (please describe)

NAD.43. Skin rash by physical exam:

 No  Yes  Unknown
NAD.44. (please describe)

NAD.45. Other abnormalities identified: please check all that apply

 Fetal Brain Disruption Sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)

 Encephalocele  Anencephaly/ Acrania  Spina bifida  Holoprosencephaly/arhinencephaly

 Microphthalmia/Anophthalmia  Arthrogryposis (congenital joint contractures)

 Congenital Talipes Equinovarus (clubfoot)  Congenital hip dislocation/developmental dysplasia of the hip

 Other abnormalities

NAD.46. (please describe below)

Neonate Imaging and Diagnostics

NAD.47. Hearing screening : (date:____/_____/_____) or Age _______ day(s)

NAD.48.  Pass  Fail  Inconclusive/Needs retest  Not performed

NAD.49. Please describe

NAD.50. Audiological evaluation:  Not performed  Auditory brainstem response (ABR) test performed

 Otoacoustic emisions (OAE) test performed  Acoustic stapedius reflex (ASR) test performed

 Unknown

NAD.51. If performed: Date: ___/___/___ NAD.52.  Normal  Abnormal,

NAD.53. Please describe

NAD.54. Retinal exam (with dilation):  Not Performed  Performed  Unknown

NAD.55. If performed: (date: _____/_____/_____) or Age _______ day(s)

NAD.56. please check all that apply:  Normal

 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

NAD.57. (please describe below)

NAD.58. Imaging study:  Cranial ultrasound  MRI  CT  Not Performed

NAD.59. (date: _____/_____/_____) or Age _______ day(s)
NAD.60. Findings: check all that apply  Normal

 Microcephaly  Intracranial calcification  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

NAD.61. (please describe below)

NAD.62. Imaging study:  Cranial ultrasound  MRI  CT  Not Performed

NAD.63. (date: _____/_____/_____) or Age _______ day(s)
NAD.64. Findings: check all that apply  Normal

 Microcephaly  Intracranial calcification  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

NAD.65. (please describe below)

NAD.66. Imaging study:  Cranial ultrasound  MRI  CT  Not Performed

NAD.67. (date: _____/_____/_____) or Age _______ day(s)

NAD.68. Findings: check all that apply  Normal

 Microcephaly  Intracranial calcification  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

NAD.69. (please describe below)

NAD.70. Was a lumbar puncture performed:  Yes  No  Unknown NAD.71. (date: _____/_____/_____) or Age _______ day(s)

Postnatal Infection Testing (includes urine culture for CMV)

NAD.72.

Toxoplasmosis infection:

 No  Yes  Unknown

NAD.73.

Cytomegalovirus infection:

 No  Yes  Unknown

NAD.74.

Herpes Simplex infection:

 No  Yes  Unknown

NAD.75.

Rubella infection:

 No  Yes  Unknown

NAD.76.

Lymphocytic choriomeningitis virus infection:

 No  Yes  Unknown

NAD.77.

Syphilis infection:

 No  Yes  Unknown

NAD.78. If yes for any postnatal infection testing, please describe results:

Postnatal (Infant) Cytogenetic Testing

NAD.79. Cytogenetic Test  Karyotype  FISH  CGH microarray  Other, specify ____________________	NAD.80. Date: _____/_____/______ NAD.81. Infant Age: _____ months	NAD.82. Specimen  Cord blood  Peripheral blood  Tissue  Other, specify ____________________	NAD.83. Test Result  Normal  Abnormal  Unknown
NAD.84. Description of cytogenetic test findings (verbatim):

NAD.85. Other tests/results/diagnosis (include dates):

Birth Defects Diagnosed or Suspected (Include Chromosomal Abnormalities and Syndromes)

Diagnostic Code

Certainty

Verbatim Description

Definite

Possible/Probable

Definite

Possible/Probable

Definite

Possible/Probable

Definite

Possible/Probable

Definite

Possible/Probable

Definite

Possible/Probable

Health Department Information

NAD.86. Name of person completing form: ________________________________________________

NAD.87. Phone: _______________

NAD.88. Email: ________________________ NAD.89. 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)

Version 8/31/2016