Form assigned Enhanced HIV/AIDS Surveillance to Maximally Reduce Perin

Attachment C. Adult HIV/AIDS Confidential Case Report Form
Form name: Adult HIV/AIDS Confidential Case Report Form (CDC 50.42A)
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:

County:

ADULT HIV/AIDS CONFIDENTIAL CASE REPORT

U.S. DEPARTMENT OF HEALTH
& HUMAN SERVICES
Centers for Disease Control
and Prevention

(Patients >13 years of age at time of diagnosis)
II. HEALTH DEPARTMENT USE ONLY

DATE FORM COMPLETED:
Day

State:

– Patient identifier information is not transmitted to CDC! –

RETURN TO STATE/LOCAL HEALTH DEPARTMENT

Mo.

Zip
Code:

REPORT
STATUS:
New
1 Report
2 Update

SOUNDEX
CODE:

Yr.

REPORT SOURCE:

Form Approved OMB No. 0920-0573 Exp Date 11/30/2005

REPORTING HEALTH DEPARTMENT:

State
Patient No.:

State:

City/County
Patient No.:

City/
County:

III. DEMOGRAPHIC INFORMATION
DIAGNOSTIC STATUS
AGE AT DIAGNOSIS:
AT REPORT (check one):
Years
1 HIV Infection (not AIDS)
2 AIDS

DATE OF BIRTH:
Mo.

Day

CURRENT STATUS:

Yr.

Alive Dead
1

Years

SEX:

ETHNICITY: (select one)

1 Male

1 Hispanic

2 Female

2 Not Hispanic or Latino

2

RACE: (select one or more)

9 Unk

American Indian/
1 Alaska Native
2 Asian

5 White

DATE OF DEATH:
Mo.

Day

STATE/TERRITORY OF DEATH:

Yr.

9
COUNTRY OF BIRTH:
(including
1 U.S. 7 U.S. Dependencies and Possessions Puerto Rico)
(specify):

3 Black or African American

Native Hawaiian or
4 Other Pacific Islander

Unk.

9 Unk

8 Other (specify):

9 Unk

RESIDENCE AT DIAGNOSIS:
City:

Zip
Code:

State/
Country:

County:

IV. FACILITY OF DIAGNOSIS

V. PATIENT HISTORY
AFTER 1977 AND PRECEDING THE FIRST POSITIVE HIV ANTIBODY TEST
OR AIDS DIAGNOSIS, THIS PATIENT HAD (Respond to ALL Categories):

Facility Name

•
•
•
•

City
State/Country
FACILITY SETTING (check one)
1 Public

2 Private

3 Federal

disorder:

9 Unk.

•

FACILITY TYPE (check one)
01 Physician, HMO

Sex with male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sex with female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Injected nonprescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Received clotting factor for hemophilia/coagulation disorder . . . . . . . . . . . . . . . . . . . .
Specify 1 Factor VIII
2 Factor IX
8 Other
(Hemophilia B)

•
•
•

Received transplant of tissue/organs or artificial insemination . . . . . . . . . . . . . . . . . .
Worked in a health-care or clinical laboratory setting . . . . . . . . . . . . . . . . . . . . . . . . . . .

88 Other (specify):___________________________

Mo.

Yr.

First

No

1

0

Unk.
9

1

0

9

1

0

9

1

0

9

(specify): _________________________________

HETEROSEXUAL relations with any of the following:
• Intravenous/injection drug user . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Bisexual male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Person with hemophilia/coagulation disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Transfusion recipient with documented HIV infection . . . . . . . . . . . . . . . . . . . . .
• Transplant recipient with documented HIV infection . . . . . . . . . . . . . . . . . . . . . .
• Person with AIDS or documented HIV infection, risk not specified . . . . . . .
Received transfusion of blood/blood components (other than clotting factor) . . .

31 Hospital, Inpatient

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).

(Hemophilia A)

Yes

Mo.

Yr.

1

0

9

1

0

9

1

0

9

1

0

9

1

0

9

1

0

9

1

0

9

1

0

9

1

0

9

Last

(specify occupation): ______________________________________

VI. LABORATORY DATA
1. HIV ANTIBODY TESTS AT DIAGNOSIS:
Neg

Ind

Not
Done

(Indicate first test)
• HIV–1 EIA . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pos

1

0

–

9

• HIV–1/HIV–2 combination EIA. . . . . . .
• HIV–1 Western blot/IFA. . . . . . . . . . . . . .
• Other HIV antibody test. . . . . . . . . . . . . .

1

0

–

9

1

0

8

9

1

0

8

9

TEST DATE
Mo.

Yr.

Mo.

• Date of last documented negative HIV test

Yr.

(specify type): _______________________________________

• If HIV laboratory tests were not documented, is HIV

diagnosis documented by a physician? . . . . . . . . . . . . . . . . .

Yes

No

1

0

Unk.
9

Mo.

Yr.

Mo.

Yr.

Mo.

Yr.

If yes, provide date of documentation by physician . . . . .

(specify):______________________

2. POSITIVE HIV DETECTION TEST: (Record earliest test)

culture

antigen

Mo.

Yr.

AT OR CLOSEST TO CURRENT DIAGNOSTIC STATUS

PCR, DNA or RNA probe

•
•

• Other (specify):_________________________________
3. DETECTABLE VIRAL LOAD TEST: (Record most recent test)
Test type*

COPIES/ML

,

Mo.

Yr.

,

*Type: 11. NASBA (Organon) 12. RT-PCR (Roche) 13. bDNA(Chiron) 18. Other
CDC 50.42A

REV. 01/2003 (Page 1 of 2)

4. IMMUNOLOGIC LAB TESTS:

CD4 Count . . . . . . . . . . . . . . .

,

CD4 Percent . . . . . . . . . . . . . . . . . . . .

cells/µL

%

First <200 µL or <14%

•
•

CD4 Count . . . . . . . . . . . . . . .

,

CD4 Percent . . . . . . . . . . . . . . . . . . . .

– ADULT HIV/AIDS CONFIDENTIAL CASE REPORT –

cells/µL

%

VII. STATE/LOCAL USE ONLY

Phone No.: (

Physician's Name:
(Last, First, M.I.)

Medical
Record No.

)

Person
Completing Form:

Hospital/Facility:

Phone No.: (

)

– Patient identifier information is not transmitted to CDC! –

VIII. CLINICAL STATUS
CLINICAL
RECORD REVIEWED:

Yes
1

No
0

Asymptomatic

ENTER DATE PATIENT
WAS DIAGNOSED AS:
Initial Diagnosis

AIDS INDICATOR DISEASES

Def.

Pres.

Candidiasis, bronchi, trachea, or lungs

1

NA

Candidiasis, esophageal

1

2

Carcinoma, invasive cervical

1

Coccidioidomycosis, disseminated or
extrapulmonary

Mo.

Yr.

Symptomatic

(including acute retroviral syndrome and
persistent generalized lymphadenopathy):
Initial Date

Initial Diagnosis

AIDS INDICATOR DISEASES

Def.

Pres.

Lymphoma, Burkitt's (or equivalent term)

1

NA

Lymphoma, immunoblastic (or equivalent term)

1

NA

NA

Lymphoma, primary in brain

1

NA

1

NA

Mycobacterium avium complex or M.kansasii,
disseminated or extrapulmonary

1

2

Cryptococcosis, extrapulmonary

1

NA

M. tuberculosis, pulmonary*

1

2

Cryptosporidiosis, chronic intestinal
(>1 mo. duration)

1

NA

M. tuberculosis, disseminated or extrapulmonary*

1

2

Cytomegalovirus disease (other than in liver,
spleen, or nodes)

1

NA

Mycobacterium, of other species or unidentified
species, disseminated or extrapulmonary

1

2

Cytomegalovirus retinitis (with loss of vision)

1

2

Pneumocystis carinii pneumonia

1

2

HIV encephalopathy

1

NA

Pneumonia, recurrent, in 12 mo. period

1

2

Herpes simplex: chronic ulcer(s) (>1 mo. duration);
or bronchitis, pneumonitis or esophagitis

1

NA

Progressive multifocal leukoencephalopathy

1

NA

Histoplasmosis, disseminated or extrapulmonary

1

NA

Salmonella septicemia, recurrent

1

NA

Isosporiasis, chronic intestinal (>1 mo. duration)

1

NA

Toxoplasmosis of brain

1

2

Kaposi's sarcoma

1

2

Wasting syndrome due to HIV

1

NA

Def. = definitive diagnosis

Mo.

Yr.

Mo.

Yr.

(not AIDS) :
Initial Date
Mo.

Yr.

* RVCT CASE NO.:

Pres. = presumptive diagnosis

• If HIV tests were not positive or were not done, does this patient have

an immunodeficiency that would disqualify him/her from the AIDS case definition?

1 Yes

0 No

9 Unknown

IX. TREATMENT/SERVICES REFERRALS
Has this patient been informed of his/her HIV infection?

1 Yes

0 No

9 Unk.

This patient’s partners will be notified about their HIV exposure and counseled by:
1 Health department
2 Physician/provider
3 Patient
9 Unknown
This patient received or is receiving:
Yes
• Anti-retroviral
therapy ............. 1

No Unk.
0

9

Yes No Unk.
.
• PCP prophylaxis

1

0

9

This patient has been enrolled at:
Clinical Trial
Clinic
1 NIH-sponsored
1 HRSA-sponsored
2 Other
2 Other
3 None
3 None
9 Unknown
9 Unknown

This patient is receiving or has
Yes No
been referred for:
• HIV related medical services . . . . . . . . 1 0
• Substance abuse treatment services 1 0

–

9

8

9

This patient’s medical treatment is primarily reimbursed by:
1

Medicaid

2

Private insurance/HMO

3

No coverage

4

Other Public Funding

7

Clinical trial/
9 Unknown
government program

• This patient is receiving or has been referred for gynecological or obstetrical services: . . . . . . . . . . . . . . . . . 1 Yes
• Is this patient currently pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Yes
• Has this patient delivered live-born infants? . . . . . . . . . . . . 1 Yes (if delivered after 1977, provide birth information

FOR WOMEN:

NA Unk.

0 No

9 Unknown

0 No

9 Unknown

0 No

9 Unknown

below for the most recent birth)

CHILD’S DATE OF BIRTH:
Mo.

Day

Yr.

Child’s Soundex:

Child’s State Patient No.

Hospital of Birth:
City:

State:

X. COMMENTS:

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 50.42A

REV. 01/2003 (Page 2 of 2)

– ADULT HIV/AIDS CONFIDENTIAL CASE REPORT –