0920-1297 Pregnancy Module - Pregnant Women/Neonate Form) REVISED

SARS-CoV-2 Epidemiologic Data Collections

COVID-19_Pregnancy_Module_V2.0_Final 16-Sep-2020_Updated

Epidemiologist - Pregnancy Module

OMB: 0920-1297

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Form Approved: OMB Control No. 0920-1297 Exp. 11/30/2020

Human Infection with 2019 Novel Coronavirus

Case Report Form – Pregnancy Module 2.0

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



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 (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



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: ______________________ )

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: __________________

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 (0920-1297).

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