Attachment D. Pediatric HIV/AIDS Confidential Case Report Form
Form name: Pediatric HIV/AIDS Confidential Case Report Form (CDC 50.42B)
Status: Currently in use
Proposed revision: Blank space at the top and bottom. Note that the burden statement
will also be updated to indicate 20 minutes and correct MS number
as stated below:
Public reporting burden of this collection of information is estimated to average 20 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta,
GA 30333, ATTN: PRA (0920-XXXX). Do not send completed form to this address.
V. PATIENT/MATERNAL HISTORY (Respond to ALL categories)
Before the diagnosis of HIV Infection/AIDS, this child had:
•
Received clotting factor for hemophilia/coagulation disorder ...........
1
0
9
•
Received transfusion of blood/blood components
(other than clotting factor) ................................................................
1
0
9
•
Received transplant of tissue/organs ..............................................
1
0
9
•
Sexual contact with a male
.............................................................
1
0
9
•
Sexual contact with a female
..........................................................
1
0
9
•
Injected nonprescription drugs ........................................................
1
0
9
•
Other (Alert State/City NIR Coordinator) ........................................
1
0
9
Mo. Yr.
1
Factor VIII
(Hemophilia A)
2
Factor IX (
Hemophilia B)
Mo. Yr.
After 1977, this child’s biologic mother had:
•
Injected nonprescription drugs ..........................................................
1
0
9
• HETEROSEXUAL relations with:
- Intravenous/injection drug user .....................................................
1
0
9
- Bisexual male ................................................................................
1
0
9
- Male with hemophilia/coagulation disorder ...................................
1
0
9
- Transfusion recipient with documented HIV infection ...................
1
0
9
- Transplant recipient with documented HIV infection ....................
1
0
9
- Male with AIDS or documented HIV infection, risk not specified
..
1
0
9
•
Received transfusion of blood/blood components
(other than clotting factor) ................................................................
1
0
9
•
Received transplant of tissue/organs or artificial insemination
.........
1
0
9
(specify
disorder):
01
Physician, HMO
31
Hospital, Inpatient
88
Other (specify):
IV. FACILITY OF DIAGNOSIS
1
Public
2
Private
3
Federal
9
Unk.
FACILITY SETTING (check one)
FACILITY TYPE (check one)
Unk.
Yes
No
1
Refused HIV testing
2
Known to be uninfected after this child’s birth
Diagnosed with HIV Infection/AIDS:
3
Before this child’s pregnancy
5
At time of delivery
7
After the child’s birth
4
During this child’s pregnancy
6
Before child’s birth, exact period unknown
8
HIV-infected, unknown when diagnosed
CDC 50.42B Rev. 01/2003 (Page 1 of 4)
– PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT –
1
U.S.
7
8
Other
1
Male
2
Female
Patient's Name:
REPORTING HEALTH DEPARTMENT:
State:
SOUNDEX
CODE:
Mo. Day Yr.
DATE FORM COMPLETED:
State
Patient No.:
City/County
Patient No.:
City/
County:
(
)
Yes No
Unk.
DATE OF DEATH:
CURRENT
STATUS:
RESIDENCE AT DIAGNOSIS:
State/
Country:
City:
County:
DATE OF BIRTH:
Years
COUNTRY OF BIRTH:
ETHNICITY:
(select one)
Zip
Code:
REPORT
STATUS:
SEX:
9
Unk.
City:
County:
(Last, First, M.I.)
III. DEMOGRAPHIC INFORMATION
Phone No.:
STATE/TERRITORY
OF DEATH:
1
2
Update
New
Report
Mo. Day Yr.
II. HEALTH DEPARTMENT USE ONLY
U.S. DEPARTMENT OF HEALTH
& HUMAN SERVICES
Centers for Disease Control
and Prevention
– Patient identifier information is not transmitted to CDC! –
REPORT SOURCE:
Address:
State:
Zip
Code:
HIV Infection
(not AIDS) ...
AIDS ............
Months
PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT
(Patients <13 years of age at time of diagnosis)
AGE AT DIAGNOSIS:
3
Perinatally HIV Exposed
5
AIDS
4
Confirmed HIV Infection (not AIDS)
6
Seroreverter
DATE OF INITIAL
EVALUATION FOR
HIV INFECTION:
Form Approved OMB No. 0920-0573 Exp Date 11/30/2005
1
Alive
2
Dead
9
Unk.
DATE OF LAST MEDICAL EVALUATION:
Mo. Yr.
1 0
9
Was reason for initial
HIV evaluation due to
clinical signs and
symptoms?
Facility
Name:
City:
State/
Country:
•
Date of mother’s first positive HIV confirmatory test: .....................
•
Mother was counseled about
HIV testing during this pregnancy, labor or delivery? .................
1
0
9
Unk.
Yes
No
U.S. Dependencies and Possessions (including Puerto Rico)
(specify):
Mo. Day Yr.
Mo. Yr.
Mo. Yr.
First: Last:
8
Other
(specify): _____________________________________________
Unk.
Yes
No
9
HIV status unknown
DIAGNOSTIC STATUS AT REPORT:
(check one)
(specify):
•
Child’s biologic mother’s HIV Infection Status: (check one)
R E T U R N T O S T A T E / L O C A L H E A L T H D E P A R T M E N T
I. STATE/LOCAL USE ONLY
1
American Indian/
Alaska Native
Native Hawaiian or
Other Pacific Islander
Not Hispanic
or Latino
Black or African American
RACE: (select one or more)
Asian
White
Unk
2
3
4
5
9
1
Hispanic
2
9
Unk.
VIII. CLINICAL STATUS
Def. Pres. Mo. Yr.
1
2
1
NA
1
NA
1
NA
1
NA
1
2
1
NA
1
NA
1
NA
1
NA
1
2
Def. = definitive diagnosis Pres. = presumptive diagnosis
1
NA
1
NA
1
2
1
2
1
NA
1
2
1
NA
1
2
1
2
Lymphoma, immunoblastic (or equivalent term)
Lymphoma, primary in brain
Mycobacterium avium complex or M.kansasii,
disseminated or extrapulmonary
M. tuberculosis, disseminated or extrapulmonary
*
Mycobacterium, of other species or unidentified
species, disseminated or extrapulmonary
Pneumocystis carinii pneumonia
Progressive multifocal leukoencephalopathy
Toxoplasmosis of brain, onset at >1 mo. of age
Wasting syndrome due to HIV
Kaposi's sarcoma
Candidiasis, esophageal
Coccidioidomycosis, disseminated or
extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic intestinal
(>1 mo. duration)
Cytomegalovirus disease (other than in liver,
spleen, or nodes) onset at >
1
mo. of age
Cytomegalovirus retinitis (with loss of vision)
HIV encephalopathy
Herpes simplex: chronic ulcer(s) (>1 mo. duration); or bron-
chitis, pneumonitis or esophagitis, onset at >1 mo. of age
Histoplasmosis, disseminated or extrapulmonary
Isosporiasis, chronic intestinal (>1 mo. duration)
1
NA
Candidiasis, bronchi, trachea, or lungs
AIDS INDICATOR DISEASES
1
NA
Lymphoma, Burkitt's (or equivalent term)
1
NA
Physician's Name:
(
)
(Last, First, M.I.)
Phone No.:
Hospital/Facility:
Medical
Record No.
Person
Completing Form:
(
)
Phone No.:
– PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT –
CDC 50.42B Rev. 01/2003 (Page 2 of 4)
Bacterial infections, multiple or recurrent
(including Salmonella septicemia)
1
2
Lymphoid interstitial pneumonia and/or
pulmonary lymphoid hyperplasia
VII. LABORATORY DATA
TEST DATE
• HIV culture ....................................................
•
HIV culture ....................................................
•
HIV antigen test ............................................
•
HIV antigen test ............................................
2. HIV DETECTION TESTS:
,
cells/
µ
L
%
4. IMMUNOLOGIC LAB TESTS:
1
0
8
9
1
0
8
9
6. If laboratory tests were not documented,
is patient confirmed by a physician as:
• HIV-infected ..........................................
• Not HIV-infected ...................................
1
0
9
Mo. Yr.
Mo. Yr.
Mo. Yr.
Mo. Yr.
– Physician identifier information is not transmitted to CDC! –
TEST DATE
(At or closest to current diagnostic status)
(Record all tests, include earliest positive)
1
0
9
1
0
9
1
0
9
1
0
9
Not
Done
•
HIV–1 EIA ..........................................................................................................................................................
•
HIV–1 EIA ..........................................................................................................................................................
•
HIV–1/HIV–2 combination EIA ..........................................................................................................................
•
HIV–1/HIV–2 combination EIA ..........................................................................................................................
•
HIV–1 Western blot/IFA .....................................................................................................................................
•
HIV–1 Western blot/IFA .....................................................................................................................................
•
Other HIV antibody test (specify):
___________________________________________________________
(Record all tests, include earliest positive)
1. HIV ANTIBODY TESTS AT DIAGNOSIS:
1
0
8
9
1
Definitive
2
Presumptive
If yes, initial
diagnosis and date:
Has this child been diagnosed
with pulmonary tuberculosis?
*
*
RVCT CASE NO.:
Yes No
Unk.
1 0
9
1
Yes
0
No
9
Unk.
Mo. Yr.
AIDS INDICATOR DISEASES
1
0
–
9
1
0
–
9
1
0
–
9
1
0
–
9
Date of Documentation
%
,
cells/
µ
L
• CD4 Percent ...................................................
• CD4 Percent ...................................................
• CD4 Count ......................................
• CD4 Count ......................................
5. If HIV tests were not positive or were not done, or the patient is less
than 18 months of age, does this patient have an immunodeficiency
that would disqualify him/her from the AIDS case definition? ..............
Def. Pres. Mo. Yr.
Initial Diagnosis Initial Date
1 0
9
3. HIV VIRAL LOAD TEST: (Record all tests, include earliest detectable)
Test type*
Copies/ml
*Type: 11. NASBA (Organon) 12. RT-PCR (Roche) 13. bDNA(Chiron) 18. Other
•
HIV DNA PCR ..............................................
•
HIV DNA PCR ..............................................
•
HIV RNA PCR ..............................................
•
HIV RNA PCR ..............................................
•
Other, specify ________________________
Mo. Yr.
1
0
9
1
0
9
1
0
9
1
0
9
Not
Done
1
0
9
TEST DATE
Positive
Not
Done
Indeterminate
Yes No
1
0
Detectable
Test Date
Initial Diagnosis Initial Date
Mo. Yr.
Yes No Unk.
Test type*
Copies/ml
Yes No
1
0
Detectable
Test Date
Mo. Yr.
Negative
Positive Negative
Positive Negative
VI. STATE/LOCAL USE ONLY
Maternal Date of Birth
Mo. Day Yr.
Clinical Trial
1
NIH-sponsored
2
Other
3
None
9
Unk.
X. TREATMENT/SERVICES REFERRALS
XI. COMMENTS:
This child received or is receiving:
This child’s medical treatment is primarily reimbursed by:
Maternal State Patient No.
Maternal Soundex:
HOSPITAL AT BIRTH:
Hospital:__________________________________________ City: _____________________________ State: ____________________ Country: _______________________
IX. BIRTH HISTORY (for PERINATAL cases only)
Birth history was available for this child:
If No or Unknown, proceed to Section X.
RESIDENCE AT BIRTH:
State/
Country:
City:
County:
1
Yes
0
No
9
Unk.
lbs.
oz
grams
Birthplace of Biologic Mother:
1
Biologic
2
Other
3
Foster/Adoptive
4
Foster/Adoptive
7
Social service
8
Other
9
Unk.
parent(s)
relative
parent, relative
parent, unrelated
agency
(specify in Section XI.)
This child’s primary caretaker is:
– PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT –
CDC 50.42B Rev. 01/2003 (Page 3 of 4)
If yes, specify: _________________________________
1
0
9
If yes, what week of
pregnancy was zidovudine
(ZDV, AZT) started?
Weeks:
8 1 0 9
Refused
BIRTH:
This report to the Centers for Disease Control and Prevention (CDC) is authorized by law (Sections 304 and 306 of the Public Health Service Act, 42 USC 242b and 242k). Response in this case is voluntary for
federal government purposes, but may be mandatory under state and local statutes. Your cooperation is necessary for the understanding and control of HIV/AIDS. Information in CDC’s HIV/AIDS surveillance
system that would permit identification of any individual on whom a record is maintained, is collected with a guarantee that it will be held in confidence, will be used only for the purposes stated in the assurance on
file at the local health department, and will not otherwise be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m).
Public reporting burden of this collection of information is estimated to average 10 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, Project Clear-
ance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0009). Do not send the completed form to this address.
Zip
Code:
8 1 0 9
Refused
BIRTHWEIGHT:
(enter lbs/oz OR grams)
Delivery:
.............
Code:
Specify
type(s):
1
Full term
2
Premature
Weeks
PRENATAL CARE:
Month of pregnancy
prenatal care began:
mos.
Total number of
prenatal care visits:
1
U.S.
7
U.S. Dependencies and Possessions (including Puerto Rico) (specify): ____________________________________________________
8
Other (specify): ___________________________________________________
9
Unk.
Did mother receive
zidovudine (ZDV, AZT)
during pregnancy?
Did mother receive
zidovudine (ZDV, AZT)
during labor/delivery?
Did mother receive any other
Anti-retroviral medication
during pregnancy?
Did mother receive
zidovudine (ZDV, AZT)
prior to this pregnancy?
Yes No
Unk.
1 0
9
•
•
•
•
•
Mo. Day Yr.
•
Other neonatal anti-retroviral medication
for HIV prevention ............................................
DATE STARTED
Was child breastfed?
This child has been enrolled at:
1
Medicaid
2
Private insurance/HMO
3
No coverage
Yes No
Unk.
1
0
9
Yes No
Unk.
1
0
9
Yes No
Unk.
1 0
9
•
Neonatal zidovudine (ZDV, AZT)
for HIV prevention ............................................
(XI. COMMENTS CONTINUED ON THE BACK)
Yes No
Unk.
Yes No
Unk.
•
99 = Unk.
99 = Unk.
99 = Unk.
Type:
....
NEONATAL
STATUS:
Birth Defects:
....
1
Vaginal
2
Elective Caesarean
3
Non-elective Caesarean
4
Caesarean, unk. type
9
Unk.
Mo. Day Yr.
DATE STARTED
Yes No
Unk.
1
0
9
1
0
9
If yes, specify: __________________________________________________________
Clinic
1
HRSA-sponsored
2
Other
3
None
9
Unk.
4
Other Public Funding
7
Clinical trial/government program
9
Unk.
•
PCP prophylaxis ....................
•
Anti-retroviral therapy
for HIV treatment ...................
99 = Unk.
If yes, specify: _________________________________
Did mother receive any other
Anti-retroviral medication
during labor/delivery?
•
Yes No
Unk.
1 0
9
1
Single
2
Twin
3
>2
9
Unk.
1
Yes
0
No
9
Unk.
00 = None
00 = None
XI. COMMENTS (continued)
– PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT –
CDC 50.42B Rev. 01/2003 (Page 4 of 4)
| File Type | application/pdf |
| File Title | Microsoft Word - Attachment D cover.doc |
| Author | pas3 |
| File Modified | 2006-11-02 |
| File Created | 2006-11-01 |