Infant Health Follow-Up Form

Infant’s State/Territory ID __________________ Registry ID __________ Mother’s State/Territory ID ________________

Approved OMB No. 0920-1101 Exp. 08/31/2016

U.S. Zika Pregnancy Registry and Birth Defects Surveillance — Integrated Infant Follow-Up 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
Infant follow up:  2 months  6 months  12 months  ___ months
IFU.1. State/Territory reporting _________________ IFU.2. Date of infant examination _____/_____/____
IFU.3. Infant’s State/Territory ID _________________	IFU.4. Mother’s State/Territory ID ____________________			IFU.5. DOB: ____/_____/_____		IFU.6. Sex:  Male  Female  Ambiguous/undetermined
IFU.7. Infant Death:  No  Yes IFU.8. If yes, cause of death __________________________ IFU.9. If yes, Date _____/_____/____ or Age at death ________  Unknown
IFU.10. Weight: _______grams or ____ lbs_____ oz			IFU.11. Length: _______ cm or _______ in		IFU.12. Head circumference: _______ cm or _______ in
IFU.13. Infant findings for corrected age at examination: (For infants born preterm, please account for corrected age: chronological age minus weeks born before 40 weeks’ gestation) Check all that apply  Normal  Microcephaly (head circumference <3%ile)  Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)  Anencephaly/ acrania  Encephalocele  Spina bifida  Holoprosencephaly/arhinencephaly  Microphthalmia/Anophthalmia  Hypertonia/Spasticity  Hyperreflexia  Irritability  Tremors  Splenomegaly  Hepatomegaly  Skin rash  Swallowing/feeding difficulties  Arthrogryposis (congenital joint contractures)  Congenital talipes equinovarus (clubfoot)  Congenital hip dislocation/developmental dysplasia of the hip  Other abnormalities IFU.14. Please list other abnormal findings:
IFU.15. Development assessment for corrected age at examination: (For infants born preterm, please account for corrected age: chronological age minus weeks born before 40 weeks’ gestation)  Normal  Abnormal  Unknown IFU.16. If developmental delay, in what area? Please check all that apply  Gross motor  Fine motor  Cognitive, linguistic and communication  Socio-Emotional
Special Studies Since Last Follow-up
IFU.17. Imaging study:  Cranial ultrasound  MRI  CT  Other _____________  Not Performed  Unknown IFU.18. Date: _____/_____/_____ IFU.19. Findings: check all that apply  Normal  Microcephaly  Intracranial calcifications  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 IFU.20. Please describe below
IFU.21. Imaging study:  Cranial ultrasound  MRI  CT  Other ______________  Not Performed  Unknown IFU.22. Date: _____/_____/_____ IFU.23. Findings: check all that apply  Normal  Microcephaly  Intracranial calcifications  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 IFU.24. (please describe below)
IFU.25. Hearing screening or re-screening:  Not performed  Performed  Unknown IFU.26. If performed: Date: ____/____/____ IFU.27.  Pass  Fail or referred, IFU.28. Please describe
IFU.29. Audiological evaluation:  Not performed  Performed  Unknown IFU.30. If performed: Date: ____/____/____ IFU.31.  Normal  Abnormal, IFU.32. Please describe
IFU.33. Retinal exam (with dilation):  Not Performed  Performed  Unknown IFU.34. If performed: Date: _____/_____/_____ IFU.35. Findings: Check all that apply:  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 IFU.36. Please describe
IFU.37. Other abnormal tests/results/diagnosis (include dates):  No  Yes IFU.38. Date: _____/_____/_____ IFU.39. Please describe
Health Department Information
IFU.40. Name of person completing form: _______________________________________________________ IFU.41. Phone: _______________ IFU.40. Email: ________________________ IFU.42. Date of form completion _____/_____/____
Internal use only
Date entered____/_____/_____ Data Entry POC Initials: ________		Data Entry Notes:
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