Facility Staff Medical Record Abstraction

Attachment 4c

Minimal Data Collection Form for Medical Monitoring Project (MMP)

Medical Monitoring Project (MMP)

Minimum Data Set Fields

Public reporting burden of this collection of information is estimated to average 3 minutes per patient record pulled, 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 (0920-0740). Do not send the completed form to this address.

Note to interviewers: This information should be obtained for all sampled MMP patients. This information is collected even if there is an interview or a medical record abstraction that has been completed for the patient. These data will be obtained via HARS or EHARS data extraction. A SAS program and an MDS Excel spreadsheet will be supplied by CDC to facilitate the extraction of the following data elements from HARS or eHARS. Please be sure to complete the Excel spreadsheet before you attempt to run the SAS code. All information on the sheet will be generated from the SAS program using the HARS /eHARS data file.

Participant ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

(PARID)

D

(SourceMin)

ata Source:  1 HARS  2 eHARS

 8 Other (specify): __________________________________

(SourcOth)

Date Form Completed

(Date of HARS Case Report or Date of Facility Record): ___ ___ / ___ ___ / ___ ___ ___ ___

(hcompltd or complted) m m d d y y y y

Date of Birth: ___ ___ / ___ ___ / ___ ___ ___ ___

(birth) m m d d y y y y

Diagnostic Status

at Report:  1 HIV Infection (not AIDS)  2 AIDS

(check one)

(diagstat)

Age at First HIV Diagnosis: ___ ___ (years)

(hage_yrs)

Age at First AIDS Diagnosis: ___ ___ (years)

(age_yrs)

Sex:  1 Male  2 Female

(sex)

E

(select one)

thnicity:  1 Hispanic/Latino  2 Not Hispanic/Latino  9 Unknown

(hisp)

R

(select all that apply)

ace:  American Indian/Alaska Native (race_i)  White (race_w)

 Black or African American (race_b)  Unknown (race_u)

 Asian (race_a)

 Native Hawaiian or Other Pacific Islander (race_p)

Country of Birth:  1 United States  2 Canada



(origin)

3 Dominican Republic  4 Haiti

 5 Mexico  7 US Dependencies

 8 Other dependency (Specify:_____________________________________)

(orig_oth)

 9 Unknown

Preceding the First Positive HIV Antibody Test or AIDS Diagnosis, This Patient Had (Mode):

(respond to ALL categories)

Yes No Unknown

(sex_male) Sex with male  1  0  9

(sex_fmle) Sex with female  1  0  9

(iv) Injected nonprescription drugs  1  0  9

(bldprd) Received clotting factor  1  0  9

HETEROSEXUAL relations with any of the following:

(s_iv) •Intravenous/injection drug user  1  0  9

(s_bi) •Bisexual male  1  0  9

(s_hemo) •Person with hemophilia/coagulation disorder  1  0  9

(s_tx) •Transfusion recipient with documented HIV  1  0  9

(s_trnplt) •Transplant recipient with documented HIV  1  0  9

(s_hiv) •Person with AIDS or documented HIV, risk

not specified  1  0  9

(transfus) Received transfusion of blood/blood components

(other than clotting factor)  1  0  9

(tranplnt) Received transplant of tissue/organs or artificial

insemination  1  0  9

(hcw) Worked in a health-care or clinical laboratory

setting  1  0  9

Most Recent CD4 (CD4 Test at or Closest to Current Diagnostic Status):

(thcrecnt)

Count: ___, ___ ___ ___

(thrcmoyr)

Date: ___ ___ / ___ ___ ___ ___

(thprecent)

Percent: ___ ___ m m y y y y

This patient’s medical treatment is primarily reimbursed by:

(insurnce)

 1 Medicaid  2 Private insurance/HMO  3 No coverage

 4 Other public  7 Clinical trial/  9 Unknown

funding government program

This patient received or is receiving:

Yes No Unknown

(antiretv)

Anti-retroviral therapy............. 1  0  9

(pcpproph)

PCP prophylaxis.................… 1  0  9

08/07/2006

Modified 06/10/2008 by elf 1