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Zika Virus Disease Case Investigation Form Mobile App

The Center for Infectious Diseases, Division of Communicable Disease Control, requires the information within this app and is intended for use by health professionals only. Reportable Diseases and Conditions for specific diseases and conditions are mandated by state laws and regulations to be reported by healthcare providers and laboratories to local health officers. The Zika Virus Disease Case Investigation Form mobile app provides an easy to complete paperless version of the mandated case report form specific to the Zika Virus. The app is filled out using a smartphone or tablet. This GoCanvas app can be made HIPAA compliant and is ideal for Disease Surveillance and Reporting.

The Center for Disease Control, national centers, children’s hospital, public health and local health departments urge health care providers to promptly report infectious diseases as well as virus infections. It is important for patient safety. Pregnant women, immigrant children, illegal immigrants and travelers are at a greater risk for communicable diseases and birth defects from lack of infection control and virus transmission. This app is specific to the Zika Virus but please don’t hesitate to report any suspicious respiratory illness, flu, rash, pneumonia or virus infection. Timely reporting can stop outbreaks.

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Take a peek inside the Zika Virus Disease Case Investigation Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    CDC R-number

  • Ico textbox

    ZIKVID:

  • Ico textbox

    Person completing form:

  • Ico textbox

    Phone number:

  • Ico dropdown

    State:

  • Ico textbox

    State ID number

  • Ico integer

    Age:

  • Ico dropdown

    Sex:

  • Ico signature

    Patient Initials:

  • Ico dropdown

    Pregnant:

  • Ico integer

    If yes, gestational week at illness onset:

  • Ico date

    Dates of travel:

  • Ico multiline

    Country(s) visited:

  • Ico statictext

    Previously vaccinated for any of the following:

  • Ico checkbox

    Yellow Fever

  • Ico integer

    If yes, year of vaccination:

  • Ico checkbox

    Japanese Encephalitis

  • Ico integer

    If yes, year of vaccination:

  • Ico checkbox

    Tickborne Encephalitis

  • Ico integer

    If yes, year of vaccination:

  • Ico date

    Illness onset date:

  • Ico dropdown

    Fever

  • Ico statictext

    If yes:

  • Ico checkbox

    Subjective fever

  • Ico checkbox

    Measured fever

  • Ico decimal

    (Maximum measured temperature:)

  • Ico dropdown

    Rash

  • Ico statictext

    If yes:

  • ...and More!

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