Pregnant woman: Complete this form for any woman who is pregnant when confirmed positive for COVID-19.
Maternal 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 ELC cooperative agreement: Project W.
Contact ID: _____________ State/local case ID: _____________ NNDSS loc. Rec. ID/Case ID: _____________
Health insurance at time of COVID-19 infection (check all that apply):
☐ Private ☐ Medicaid ☐ Self-Pay ☐ None ☐ Unknown ☐ Other (Specify: ______________________ )
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 starting 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
Date of first positive specimen by SARS-CoV-2 PCR testing:__/__/____ (MM/DD/YYYY)
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) |
Was the mother admitted to an intensive care unit (ICU) for COVID-19? ☐ Yes ☐ No ☐ Unknown
If yes, date of ICU admission: __/__/____ (MM/DD/YYYY) ☐ Check if date of ICU admission is unknown
Date of ICU discharge: __/__/____ (MM/DD/YYYY) ☐ Check if date of ICU discharge is unknown
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: (Check 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 (Check all that apply): ☐ Past due date/Post-dates ☐ Maternal condition ☐ Fetal condition ☐ Premature rupture of membranes ☐ Other (Specify: __________________ ) ☐ Unknown |
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Delivery type: ☐ Vaginal ☐ Cesarean ☐ Unknown |
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If cesarean, indication: ☐ Emergent ☐ Non-emergent ☐ Unknown |
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If emergent, indication: ☐ Maternal condition ☐ Fetal condition ☐ Both (maternal and fetal) |
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☐ Unknown ☐ Other (Specify: ______________________ ) |
Maternal birth hospitalization complications (during birth admission):
Was the mother admitted to an intensive care unit (ICU) for delivery complications? ☐ Yes ☐ No ☐ Unknown
If yes, date of ICU admission: __/__/____ (MM/DD/YYYY) ☐ Check if date of ICU admission is unknown
Maternal death: ☐ Yes ☐ No ☐ Unknown
If yes, date of death __/__/____ (MM/DD/YYYY) ☐ Check if date of death is unknown
If yes, cause(s) of death: ____________________________
Additional comments:
Enter neonate information on next page
Neonate (for multiple gestations, please complete one entry for each fetal/infant outcome):
Neonate 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 ELC cooperative agreement: Project W.
Contact ID: _____________ State/local case ID: ____________ NNDSS loc. Rec. ID/Case ID: _____________
Maternal CDC 2019-nCoV ID: _____________
Sex: ☐ Male ☐ Female ☐ Other ☐ Unknown or not yet determined
Gestational age at delivery: ___weeks ___days
Was this a multiple gestation pregnancy? ☐ Yes ☐ No ☐ Unknown
Date of birth/pregnancy outcome: __/__/____ (MM/DD/YYYY) ☐ Check if date of birth/pregnancy outcome is unknown
Pregnancy outcome: ☐ 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 (Check all that apply): ☐ Past due date/Post-dates ☐ Maternal condition ☐ Fetal condition ☐ Premature rupture of membranes ☐ Other (Specify: __________________ ) ☐ Unknown |
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Delivery type: ☐ Vaginal ☐ Cesarean ☐ Unknown |
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If cesarean, indication: ☐ Emergent ☐ Non-emergent ☐ Unknown |
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If emergent, indication: ☐ Maternal condition ☐ Fetal condition ☐ Both (maternal and fetal) |
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☐ Unknown ☐ Other (Specify: ______________________ ) |
Neonate Birth weight: ___lb ___oz [or] ___kg
Neonate Birth length: ___in [or] ___cm
Infant outcomes (during birth admission):
Was the infant admitted to the intensive care unit (any type, NICU, CICU, etc.)? ☐ Yes ☐ No ☐ Unknown
If yes, date of discharge from the intensive care unit: __/__/____ (MM/DD/YYYY)
If yes, discharge diagnosis codes: __________________
Neonate death: ☐ Yes ☐ No ☐ Unknown
If yes, date of death __/__/____ (MM/DD/YYYY) ☐ Check if date of death is unknown
If yes, cause(s) of death __________________
Birth defect: ☐ Yes ☐ No ☐ Unknown If yes, specify type: __________________
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
Neonate COVID-19 testing:
Was infant tested for COVID-19 during the birth admission: ☐ Yes ☐ No ☐ Unknown
Test 1:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 2:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 3:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 4:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 5:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 6:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 7:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 8:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 9:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
Test 10:
Type: ☐ SARS-CoV-2 – Antigen ☐ SARS-CoV-2 – IgG ☐ SARS-CoV-2 – IgM ☐ SARS-CoV-2 - PCR
☐ SARS-CoV-2 – Other
Result: ☐ Positive ☐ Negative ☐ Indeterminate ☐ Unknown
Date of sample collection: __/__/____ (MM/DD/YYYY)
Specimen: ☐ Blood ☐ Nasal/NP swab ☐ Throat swab/OP Swab ☐ Combined nasal/NP+throat swab ☐ Sputum ☐ Bronchoalveolar lavage (BAL) ☐ Endotracheal Aspirate (ETA) ☐ Feces/rectal swab ☐ Other
If other, specify type: __________________
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 (0920-1297).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Boundy, Ellen (CDC/DDPHSIS/CGH/DPDM) |
File Modified | 0000-00-00 |
File Created | 2021-01-13 |