Get Zika Virus Disease Case Investigation Form

Filling out the Zika Virus Disease Case Investigation Form online is a crucial step in reporting suspected cases of Zika virus. This guide provides clear and detailed instructions on how to complete each section of the form accurately and efficiently.

Follow the steps to successfully complete the online form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by filling out the 'Reporting Jurisdiction' section. Enter the name of the person completing the form and their phone number, followed by the state where the case is reported.
3. In the 'Demographic Information' section, input the state ID number and specify the patient's age in years or months, along with their initials. Indicate if the patient is pregnant and if so, provide the gestational week at the time of illness onset. Also, select the patient's sex.
4. Next, complete the 'Travel History' section by entering the dates of travel and the country or countries visited by the patient.
5. Move on to the 'Vaccination History' section. Indicate if the patient was previously vaccinated for Yellow Fever, Japanese Encephalitis, or Tickborne Encephalitis. If applicable, record the year of each vaccination.
6. In the 'Illness Information' section, provide the date of illness onset. Document whether the patient experienced a fever and specify if it was subjective or measured, including the maximum measured temperature. Record details regarding any rash, including the type and distribution.
7. Add any additional clinical symptoms present at the time of illness, such as arthralgia, headache, conjunctivitis, myalgia, vomiting, or diarrhea.
8. Complete the 'Specimen Information' section by entering the collection dates for up to two specimens, specifying the type for each (e.g., serum, CSF, or amniotic fluid).
9. After filling out all the sections correctly, make sure to review the information provided. Save any changes made before proceeding.
10. Finally, download, print, or share the completed form as necessary.

Take a moment to complete your documents online for swift and efficient submission.