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