Form 1 Zika Data Elements Instrument

Zika Pilot Project – Data Elements

Demographics
Donor ID: _____________ Gender: Age in Years: ______________
Zika NAT Results
 Positive  Negative  Indeterminate
Clinical information
Date of symptom onset ____/____/___ OR  He/She was Asymptomatic Fever  Yes  No  Unknown Rash  Yes  No  Unknown Arthralgia  Yes  No  Unknown Conjunctivitis  Yes  No  Unknown Other symptoms: ___________________________________________________________________________________ __________________________________________________________________________________________________
Exposure information prior to symptom onset (or specimen collection if asymptomatic)
Did he/she travel to or live in a Zika endemic area in the 14 days before onset of symptoms?  Yes  No  Unknown
If yes: Country(s) or US State/territory: _________________________________________ Travel start date:____/____/______ Travel end date:____/____/______
Did he/she have sexual relations with any person who returned from travel to a country or US state or territory with known local Zika transmission in the previous 6 months (if partner was male) or 2 months (if partner was female) or who had confirmed Zika virus infection?	 Yes  No  Unknown

Page 1 of 1 October 2017