Pregnancy Module

Form Approved: OMB Control No. 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus
Case Report Form – Pregnancy Module
Pregnant woman:
Complete this form for any woman who is pregnant (any trimester) when confirmed positive for COVID-19.
CDC 2019-nCoV ID: ____________ Reporting Jurisdiction: _____________
CDC pregnancy ID*: _____________*This ID is applicable to health departments submitting data for Surveillance for Emerging
Threats to Mothers and Babies Network (SET-NET), funded through the Epidemiology Laboratory Capacity: Project W.

State/local case ID: ____________ Contact ID: ____________ NNDSS loc. Rec. ID/Case ID: _____________
Health insurance at time of COVID-19 infection (check all that apply):
☐ Private ☐ Medicaid ☐ Self-Pay ☐ Other ☐ None ☐ Unknown
Obstetric information:
Gravidity (total pregnancies): _____ Parity: (live births) _____
Estimated due date (EDD):__/__/____(MM/DD/YYYY)
☐ Check if EDD is unknown
Number of fetuses ____ (e.g., 1=singleton, 2=twins, 3=triplets)
☐ Check if number of fetuses is unknown
Pre-pregnancy weight: _____lb [or] _____kg
Height: _____ft _____in [or] _____cm
Did the mother receive prenatal care? ☐ Yes ☐ No ☐ Unknown
Pregnancy conditions (current pregnancy):
Gestational diabetes: ☐ Yes ☐ No ☐ Unknown
Hypertension that started this pregnancy: ☐ Yes ☐ No ☐ Unknown
Intrauterine growth restriction: ☐ Yes ☐ No ☐ Unknown
Trimester of COVID-19 infection:
☐ First (<14 weeks) ☐ Second (14-27 weeks) ☐ Third (≥28 weeks) ☐ Unknown
Treatment for COVID-19:
☐ Remdesivir Date started:__/__/____ (MM/DD/YYYY)
☐ Other 1 (Specify medication: _________) Date started:__/__/____ (MM/DD/YYYY)
☐ Other 2 (Specify medication: _________) Date started:__/__/____ (MM/DD/YYYY)
☐ Other 3 (Specify medication: _________) Date started:__/__/____ (MM/DD/YYYY)
For completed pregnancies, please provide the following information:
Date of birth/pregnancy outcome: __/__/____ (MM/DD/YYYY) ☐ Check if date of birth/pregnancy outcome is unknown
Pregnancy outcome (select all that apply):
☐ Miscarriage (<20 weeks gestation)
☐ Stillbirth (≥20 weeks gestation)
☐ Termination
☐ Non-live birth, not otherwise specified
☐ Live birth
☐ Unknown

Was labor induced? ☐ Yes ☐ No ☐ Unknown
If ‘yes,’ reason for induction (select all that apply):
☐ Past due date/Post-dates
☐ Maternal condition
☐ Fetal condition
☐ Premature rupture of membranes
☐ Other (Specify: __________________ )
☐ Unknown

Delivery type: ☐ Vaginal ☐ Cesarean ☐ Unknown
If cesarean, indication: ☐ Emergent ☐ Non-emergent ☐ Unknown
If emergent, indication: ☐ Maternal condition ☐ Fetal condition ☐ Both (maternal and fetal)
☐ Unknown ☐ Other (Specify: ______________________ )
Maternal birth hospitalization complications:
Maternal intensive care unit (ICU) admission: ☐ Yes ☐ No ☐ Unknown
If yes, primary reason for ICU admission: ________________________
Maternal death: ☐ Yes ☐ No ☐ Unknown
If yes, date of death __/__/____ (MM/DD/YYYY)
☐ Check if date of death is unknown
If yes, primary cause of death: ____________________________

Additional comments:
Public reporting burden of this collection of information is estimated to average 45 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 D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).

Form Approved: OMB Control No. 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus
Case Report Form – Pregnancy Module

Enter neonate information on page 2
Neonate (for multiple gestations, please complete one entry for each fetal/infant outcome):
CDC 2019-nCoV ID: ______________ Reporting Jurisdiction: ______________
CDC pregnancy ID*: _____________*This ID is applicable to health departments submitting data for Surveillance for Emerging
Threats to Mothers and Babies Network (SET-NET), funded through the Epidemiology Laboratory Capacity: Project W.

Contact ID: _____________ State/local case ID: ____________ NNDSS loc. Rec. ID/Case ID: _____________
Mom CDC 2019-nCoV ID: _____________
Sex: ☐ Male ☐ Female ☐ Undetermined ☐ Unknown
Gestational age at delivery: ___weeks ___days
Neonate Birth weight: ___lb ___oz [or] ___kg
Neonate Birth length: ___in [or] ___cm
Infant outcomes (during birth admission):
Neonate intensive care unit admission (any type, NICU, CICU, etc.): ☐ Yes ☐ No ☐ Unknown
If yes, primary reason for ICU admission: __________________
Neonate death: ☐ Yes ☐ No ☐ Unknown
If yes, date of death __/__/____ (MM/DD/YYYY)
☐ Check if date of death is unknown
If yes, primary cause of death __________________
Birth defect: ☐ Yes ☐ No ☐ Unknown
If yes, specify type: __________________
Neonate COVID-19 testing:
Infant tested for COVID-19 during the birth admission: ☐ Yes ☐ No ☐ Unknown
If tested, result:
☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
If positive, date of first positive test __/__/____ (MM/DD/YYYY)
☐ Check if date of first positive test is unknown
Birth admission practices:
Did the infant room-in with the mother during the birth admission? ☐ Yes ☐ No ☐ Unknown
Was the infant ever breastfed? ☐ Yes ☐ No ☐ Unknown
Additional comments:

Public reporting burden of this collection of information is estimated to average 45 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 D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).