The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

THvdUc3sptQcWjbGZaqis2Rpe8mwrTNqenFDLkXu43d22jUiRfEy6oPoEypbEGbviv6YNcFt9AshfmWwTtJGHFIXN6YyWYT

Congenital Cytomegalovirus Reporting Form

Congenital cytomegalovirus (cCMV) must be reported to MDH within one working day.

Case Definition: Cytomegalovirus (CMV) detected by nucleic acid amplification test (NAAT) or culture, or by antigen testing, on any specimen source, excluding dried blood, from an infant less than or equal to 90 days of age.

Today's date:

M-D-Y

Person reporting:

* must provide value

Email of person reporting:

* must provide value

Phone number:

* must provide value

Reporting facility:

* must provide value

Patient first name:

* must provide value

Patient last name:

* must provide value

Date of birth:

* must provide value

M-D-Y

Sex:

* must provide value

Specify

Address		City
State		Zip

Parent/guardian phone number

* must provide value

Mother's name:

* must provide value

Mother's date of birth:

M-D-Y

Birth hospital:

* must provide value

Reason for testing:
(Select all that apply)

Referred on hearing screen or diagnosed with hearing loss

Mother tested positive for CMV during pregnancy

Symptomatic

NICU

Positive on NBS blood spot

Other:

Specimen collection date:

* must provide value

M-D-Y

Age (days) at time of specimen collection

View equation

Ordering facility:

* must provide value

Specimen type:

* must provide value

Dried blood spot

Urine

Saliva

CSF

Blood (whole blood, serum, or plasma)

Other -

reset

Dried blood spot results do not need to be reported to the Minnesota Department of Health

Results:

* must provide value

CMV Detected (Positive)

CMV Not Detected (Negative)

Indeterminate

reset

Performing laboratory

* must provide value

Primary care clinic:

* must provide value

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