Case Report Form For Zika And Related Conditions (Page 2 of 2) in pdf

Case Report Form For Zika And Related Conditions Page 2

MSD Case Report Form for Zika Conditions (Mar 2016)

Pregnancy outcome? Live birth

Stillborn (>20 weeks)

Miscarriage (<20 weeks)

Termination

Unknown

Risk Factor Assessment – within 30 days of onset of symptoms:

Sexual contact with anyone suspected to have Zika or with a person who travelled to a Zika-affected area? Yes

Unknown

Does the patient have known mosquito exposure? Yes

Unknown

If yes, date of exposure (dd/mm/yy): ____/____/____

Exposure location: __________________________________________________________________________________

Did the patient travel?

Yes

No travel history within the past 2 weeks

Unknown

If yes, please specify travel destination(s) and itinerary:

Blood and Blood Products:

Within 30 days prior to onset of symptoms, did the patient receive blood or blood products?

Yes

Unknown

Within 30 days prior to onset of symptoms, did the patient receive organ/tissue transplant?

Yes

Unknown

Additional comments:

Reporter Information:

Date Report Submitted (dd/mm/yy): ____/____/____ Reporter First Name: ________________ Last Name: __________________

Duty Station: ______________ Organisation: ________ Dept/Office: ______________________________Title: _____________________

Phone Number: ___________________ Fax Number: ____________________ E-Mail: _________________________________________

Name of Treating Physician: _________________________ Physician Phone: _______________ Physician Email: ___________________

How long did this case report take to complete (minutes)? _____________

Please submit completed forms to or fax to: +917-367-0656.

Please attach any available medical records to this form.

For any questions, please contact MSD at

or +1-917-353-5387

For MSD’s Use Only:

Case ID #: __________________________________

Classification of Case: Suspect/Probable/Confirmed/Not a Case

Case Report Form For Zika And Related Conditions Page 2