Changes to Pediatric Case Report Form

Patient Identification
*Patient Name

*First Name

*Middle Name

*Alternate Name Type
(ex Birth, Call Me)

*Last Name

*First Name

□ Residential □ Bad Address □ Correctional Facility
□ Foster Home □ Homeless □ Postal □ Shelter □ Temporary
Address Type
City

*Middle Name

*Last Name

*Current Street Address

County

*Medical Record Number

Last Name Soundex

*Phone (

State/Country

) _______________

*ZIP Code

*Other ID Type:

Number:

Pediatric HIV Confidential Case Report Form

U.S. Department of Health
& Human Services

Centers for Disease Control
and Prevention

(Patients <13 Years of Age at Time of Diagnosis) * Information NOT transmitted to CDC

Form approved OMB no 0920-0573 Exp. 01/31/2013

Health Department Use Only
Date Received at Health Department
__ __ /__ __ /__ __ __ __

eHARS Document UID _________________

Reporting Health Dept - City / County

State Number ____________________

City/County Number

Document Source ___________________________

Surveillance Method

Did this report initiate a new case investigation?
□ Yes □ No □ Unknown

Report Medium

□ Active □ Passive □ Follow up □ Reabstraction □ Unknown

□ 1-Field Visit □ 2-Mailed □ 3-Faxed □ 4-Phone
□ 5-Electronic Transfer □ 6-CD/Disk

Facility Providing Information (record all dates as mm/dd/yyyy)
Facility Name

*Phone (

) ______________________

*Street Address
City
Facility
Type

County

□ Hospital
□ Other, specify _____________
Inpatient:

State/Country

Outpatient: □ Private Physician’s Office

□ Pediatric Clinic
□ Pediatric HIV Clinic □ Other, specify ____________­­­____­­___

Date Form Completed­­­­­­­­­­­­­­­­­­­ __ __ /__ __ /__ __ __ __

Zip Code
Other Facility: □ Emergency Room

□ Laboratory
□ Unknown □ Other, specify _________________

*Person Completing Form

*Phone (

) ______________________

Patient Demographics (record all dates as mm/dd/yyyy)
Diagnostic Status at Report □ 3-Perinatal HIV Exposure
□ 4-Pediatric HIV □ 5-Pediatric AIDS □ 6-Pediatric Seroreverter

Sex assigned at Birth
□ Male □ Female □ Unknown

Date of Birth __ __ /__ __ /__ __ __ __
Vital Status

□ 1-Alive □ 2-Dead

Date of Death __ __ /__ __ /__ __ __ __

(please specify) _____________

State of Death ______________________

Date of Initial Evaluation for HIV __ __ /__ __ /__ __ __ __

□ Hispanic/Latino □ Not Hispanic/Latino □ Unknown

Race
(check all that apply)

□ US □ Other/ US Dependency

Alias Date of Birth __ __ /__ __ /__ __ __ __

Date of Last Medical Evaluation __ __ /__ __ /__ __ __ __
Ethnicity

Country of
Birth

*ExpandedEthnicity

□ American Indian/Alaska Native □ Asian □ Black/African American
□ Native Hawaiian/Pacific Islander
□ White □ Unknown

*Expanded Race

________________

__________________

Residence at Diagnosis (add additional addresses in Comments)
Address Type
(Check all that apply to address below)

□ Residence at

HIV diagnosis

□ Residence at

AIDS diagnosis

□ Residence at

Perinatal Exposure

□ Residence at Pediatric □ Check if SAME as
Seroreverter

Current Address

* Street Address
City

County

State/Country

*ZIP Code

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).
CDC 50.42B

Rev. 2/2011

(Page 1 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

STATE/LOCAL USE ONLY

– Patient identifier information is not transmitted to CDC! –

Physician’s Name: (Last, First, M.I.)

Medical Record

______________________________________________________

Phone No: (

No.______________

) __________________

Hospital/Facility:

Person Completing Form:

___________________________________

___________________________________

Phone No: (

) __________________

Facility of Diagnosis (add additional facilities in Comments)
Diagnosis Type

□ HIV □ AIDS □ Perinatal Exposure (check all that apply to facility below) □ Check if SAME as Facility Providing Information

Facility Name

*Phone (

) ______________________

*Street Address
City
Facility
Type

County

State/Country

□ Hospital
□ Other, specify _____________

Outpatient: □ Private Physician’s Office

□ Pediatric Clinic
□ Pediatric HIV Clinic □ Other, specify _____________

Inpatient:

*Provider Name

*Provider Phone (

) ______________________

Zip Code
Other Facility: □ Emergency Room

□ Laboratory
□ Unknown □ Other, specify _________________
*Specialty

Patient History (resond to all questions) record all dates as mm/dd/yyyy)

□ 1-Refused HIV testing □ 2-Known to be uninfected after this child’s birth
□ 3-Known HIV+ before pregnancy □ 4-Known HIV+ during pregnancy
□ 5-Known HIV+ sometime before birth □ 6-Known HIV+ at delivery
□ 7-Known HIV+ after child’s birth □ 8-HIV+, time of diagnosis unknown □ 9-HIV status unknown
Child’s biological mother’s HIV infection status (select one):

Date of mother’s first positive HIV
confirmatory test:

__ __ /__ __ /__ __ __ __

Was the biological mother counseled about HIV testing during this pregnancy,
labor, or delivery? □ Yes □ No □ Unknown

After 1977 and before the earliest known diagnosis of HIV infection, this child’s biological mother had:
Perinatally acquired HIV Infection

□ Yes □  No □  Unknown

Injected drugs not prescribed for patient

□ Yes □  No □  Unknown

Biological Mother had HETEROSEXUAL relations with any of the following:
HETEROSEXUAL contact with intravenous/injection drug user

□ Yes □  No □  Unknown

HETEROSEXUAL contact with bisexual male

□ Yes □  No □  Unknown

HETEROSEXUAL contact with person with hemophilia / coagulation disorder with documented HIV infection

□ Yes □  No □  Unknown

HETEROSEXUAL contact with transfusion recipient with documented HIV infection

□ Yes □  No □  Unknown

HETEROSEXUAL contact with transplant recipient with documented HIV infection

□ Yes □  No □  Unknown

HETEROSEXUAL contact with person with AIDS or documented HIV Infection, risk not specified

□ Yes □  No □  Unknown

Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments section)
First date received ___ ___ / ___ ___ / ___ ___ ___ ___ Last date received ___ ___ / ___ ___ / ___ ___ ___ ___

□ Yes □  No □  Unknown
□ Yes □  No □  Unknown

Received transplant of tissue/organs or artificial insemination
Before the diagnosis of HIV infection, this child had:

□ Yes □  No □  Unknown

Injected non-prescription drugs
Received clotting factor for hemophilia/
coagulation disorder

Specify clotting factor:
Date received (mm/ dd/yyyy): ___ ___ / ___ ___ / ___ ___ ___ ___

Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments section)
First date received ___ ___ / ___ ___ / ___ ___ ___ ___ Last date received ___ ___ / ___ ___ / ___ ___ ___ ___

□ Yes □  No □  Unknown
□ Yes □  No □  Unknown

Received transplant of tissue/organs

□ Yes □  No □  Unknown

Sexual contact with male

□ Yes □  No □  Unknown

Sexual contact with female

□ Yes □  No □  Unknown

Other Documented Risk (please include detail in Comments section)

□ Yes □  No □  Unknown

CDC 50.42B

Rev. 2/2011

(Page 2 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

Laboratory Data (record additional tests in Comments section)
HIV Antibody Tests (Non-type differentiating) [HIV-1 vs. HIV-2]
TEST 1:

□ HIV-1 EIA □ HIV-1/2 EIA □ HIV-1/2 Ag/Ab □ HIV-1 WB □ HIV-1 IFA □ HIV-2 EIA □ HIV-2 WB □ Other: Specify Test: __________________

RESULT:

□ Positive/Reactive □ Negative/Nonreactive □ Indeterminate

TEST 2:

□ HIV-1 EIA □ HIV-1/2 EIA □ HIV-1/2 Ag/Ab □ HIV-1 WB □ HIV-1 IFA □ HIV-2 EIA □ HIV-2 WB □ Other: Specify Test: __________________

RESULT:

□ Positive/Reactive □ Negative/Nonreactive □ Indeterminate

RAPID TEST (check if rapid):

RAPID TEST (check if rapid):

□ Collection Date:
□ Collection Date:

__ __ /__ __ /__ __ __ __

__ __ /__ __ /__ __ __ __

HIV Antibody Tests (Type differentiating) [HIV-1 vs. HIV-2]
TEST:

□ HIV-1/2 Differentiating (e.g., Multispot)

RESULT:

□ HIV-1 □ HIV-2 □ Both (undifferentiated) □ Neither (negative)

Collection Date: __ __ /__ __ /__ __ __ __

HIV Detection Tests (Qualitative)
TEST 1:

□ HIV-1 RNA/DNA NAAT (Qual) □ HIV-1 P24 Antigen □ HIV-1 Culture □ HIV-2 RNA/DNA NAAT (Qual) □ HIV-2 Culture

RESULT:

□ Positive/Reactive □ Negative/Nonreactive □ Indeterminate

TEST 2:

□ HIV-1 RNA/DNA NAAT (Qual) □ HIV-1 P24 Antigen □ HIV-1 Culture □ HIV-2 RNA/DNA NAAT (Qual) □ HIV-2 Culture

RESULT:

□ Positive/Reactive □ Negative/Nonreactive □ Indeterminate

Collection Date: __ __ /__ __ /__ __ __ __

Collection Date: __ __ /__ __ /__ __ __ __

HIV Detection Tests (Quantitative viral load) Note: Include earliest test after diagnosis
TEST 1:

□ HIV-1 RNA/DNA NAAT (Quantitative viral load)

RESULT:

□ Detectable □ Undetectable

TEST 2:

□ HIV-1 RNA/DNA NAAT (Quantitative viral load)

RESULT:

□ Detectable □ Undetectable

Copies/mL: _________________

Copies/mL: _________________

Log: ______________ Collection Date: __ __ /__ __ /__ __ __ __

Log: ______________ Collection Date: __ __ /__ __ /__ __ __ __

Immunologic Tests (CD4 count and percentage)
CD4 at or closest to current diagnostic status: CD4 count: _________cells/µL CD4 percentage: ____% Collection Date: __ __ /__ __ /__ __ __ __
First CD4 result <200 cells/µL or <14%: CD4 count: _______________cells/µL CD4 percentage: ____% Collection Date: __ __ /__ __ /__ __ __ __
Documentation of Tests
If laboratory tests were not documented,

HIV-Infected

is patient confirmed by a physician as:

Not HIV-Infected

□ Yes □ No □ Unknown
□ Yes □ No □ Unknown

Date of Documentation: __ __ /__ __ /__ __ __ __
Date of Documentation: __ __ /__ __ /__ __ __ __

Clinical (select D for Definitive or P for Presumptive where applicable) (record all dates as mm/dd/yyyy)
D

P

Date

D

Bacterial infection, multiple or recurrent (including
Salmonella septicemia)

Kaposi’s sarcoma

Candidiasis, bronchi, trachea, or lungs

Lymphoid interstitial pneumonia and/or pulmonary lymphoid
hyperplasia

Candidiasis, esophageal

Lymphoma, Burkitt’s (or equivalent)

Coccidiodomycosis, disseminated or extrapulmonary

Lymphoma, immunoblastic (or equivalent)

Cryptococcosis, extrapulmonary

Lymphoma, primary in brain

Cryptosporidiosis, chronic intestinal (>1 mo. duration)
Cytomegalovirus disease (other than in liver, spleen, or
nodes)

Mycobacterium avium complex or M. kansasii, disseminated
or extrapulmonary

M. tuberculosis, disseminated or extrapulmonary†
extrapulmonary

HIV encephalopathy

Pneumocystis pneumonia

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

Progressive multifocal leukoencephalopathy

Histoplasmosis, disseminated or extrapulmonary

Toxoplasmosis of brain, onset at >1 mo. of age

Isosporiasis, chronic intestinal (>1 mo. duration)

Wasting syndrome due to HIV

□ Yes □  No
□ Unknown

Date

Mycobacterium, of other/unidentified species, disseminated or

Cytomegalovirus retinitis (with loss of vision)

Has this child been
diagnosed with pulmonary
tuberculosis?

P

If Yes, initial diagnosis: □ Definitive □ Presumptive
□ Unknown

Date:

†

If TB selected above, indicate RVCT Case Number:

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 (0920-0573). Do not send the completed form to this address.
CDC 50.42B

Rev. 2/2011

(Page 3 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

Birth History (for Perinatal Cases only)
Birth History Available

□ Yes □ No □ Unknown

□ Check if SAME as Current Address

Residence at Birth

* Street Address

City

County

State/Country

*Zip Code

Hospital of Birth

□ Check if SAME as Facility Providing Information
Facility Name

*Phone (

*Street Address

) _____________

City

Zip Code

County

State/Country

Birth History
Birth Weight
Type □ 1-Single □ 2-Twin
Delivery □ 1-Vaginal □ 2-Elective Cesarean □ 3-Non-Elective Cesarean
______ lbs _______ oz ______ grams
□ 3->2 □ 9-Unknown

□ 4-Cesarean, unknown type □ 9-Unknown
Birth Defects
If yes, please specify:
□ Yes □ No
□ Unknown
Neonatal Status □ 1-Full-term □ 2-Premature
Neonatal Status Weeks:
___________ (99–Unknown)
□ Unknown
Prenatal Care – Month of
Prenatal Care - Total number of prenatal
____________
____________
Pregnancy Prenatal Care began
care visits:
(00-None, 99-Unknown)
(00-None, 99-Unknown)
Did mother receive zidovudine
If yes, what week of pregnancy was zidovudine
□ Yes □ No □ Refused
____________
(ZDV,AZT) during pregnancy:
(ZDV, AZT) started:
□ Unknown
( 99-Unknown)
Did mother receive zidovudine
Did mother receive zidovudine (ZDV,AZT) prior
□ Yes □ No □ Refused
□ Yes □ No
(ZDV,AZT) during labor/delivery:
to this pregnancy:
□ Unknown
□ Unknown
Did mother receive any other Anti-retroviral
If yes, please
□ Yes □ No
medication during pregnancy?
specify:
□ Unknown
Did mother receive any other Anti-retroviral
If yes, please
□ Yes □ No
medication during labor/delivery?
specify:
□ Unknown

Maternal Information
Maternal DOB

Maternal Soundex

Maternal Stateno

*Other Maternal ID – List Type:

Maternal Country of Birth

Number:

Services Referrals (record all dates as mm/dd/yyyy)
This child received or is receiving:
Date:
□ Yes □ No □ Unknown
Other neonatal anti-retroviral medication for HIV prevention:
□ Yes □ No □ Unknown
Neonatal zidovudine (ZDV,AZT) for HIV prevention:
If Yes, please specify: 1)

2)

Anti-retroviral therapy for HIV treatment:

3)

□ Yes □ No □ Unknown

___ ___ / ___ ___ / ___ ___ ___ ___

Date:

___ ___ / ___ ___ / ___ ___ ___ ___

4)

Date:

5)

___ ___ / ___ ___ / ___ ___ ___ ___

PCP Prophylaxis: □ Yes □ No □ Unknown Date: ___ ___ / ___ ___ / ___ ___ ___ ___
Was this child breastfed? □ Yes □ No □ Unknown
This child’s primary
□ 1- Biological Parent □ 2- Other Relative □ 3- Foster/Adoptive parent, relative □ 4- Foster/Adoptive parent, unrelated
caretaker is:
□ 7- Social Service Agency □ 8- Other (please specify in comments) □ 9- Unknown

*Comments

*Local / Optional Fields

CDC 50.42B

Rev. 2/2011

(Page 4 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—