Form 0920-0573 Adult HIV Confidential Case Report Form

Attachment 3 (a)
National HIV Surveillance System (NHSS)
OMB # 0920-0573

Adult HIV Confidential Case Report Form

1

Patient Identification
*Patient Name

*First Name

*Middle Name

*Alternate Name Type
(ex Alias, Married)

*Last Name

*First Name

Last Name Soundex

*Middle Name

*Last Name

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

County

*Phone (

State/Country

*Medical Record Number

)

*ZIP Code

*Other ID Type:

Number:

Adult HIV Confidential Case Report Form
(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

/

State Number

Reporting Health Dept - City / County

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

Outpatient: □ Private Physician’s Office
□ Adult HIV Clinic
□ Other, specify

Inpatient:

Date Form Completed

/

State/Country

Zip Code

Screening, Diagnostic, Referral
Agency:
□ CTS □ STD Clinic

□ Other, specify

*Person Completing Form

/

□ Emergency Room
□ Laboratory □ Corrections □ Unknown
□ Other, specify
Other Facility:

*Phone (

)

Patient Demographics (record all dates as mm/dd/yyyy)
Sex assigned at Birth
Date of Birth
Vital Status

□ Male □ Female □ Unknown

/

Ethnicity

□ US □ Other/ US Dependency (please specify)

Alias Date of Birth

/

□ 1- Alive □ 2- Dead

Current Gender Identity

Country of Birth

Date of Death

/

/

/

State of Death

□ Male □ Female □ Transgender Male-to-Female (MTF) □ Transgender Female-to-Male (FTM) □ Unknown
□ Additional gender identity (specify)

□ Hispanic/Latino □ Not Hispanic/Latino □ Unknown

Race
(check all that apply)

/

*Expanded Ethnicity

□ 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)
*Street Address
City

□ Residence at HIV diagnosis □ Residence at AIDS diagnosis □ Check if SAME as Current Address

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).

(Page 1 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—

– Patient identifier information is not transmitted to CDC! –

STATE/LOCAL USE ONLY
Physician’s Name: (Last, First, M.I.)

Medical Record
Phone No: (

Hospital/Facility:

No.

)

Person Completing Form:

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

□ HIV

□ AIDS

□ Check if SAME as Facility Providing Information

(check all that apply to facility below)

Facility Name

*Phone (

)

*Street Address
City
Facility
Type

County

□ Hospital
□ Other, specify
Inpatient:

State/Country

Outpatient: □ Private Physician’s Office

Screening, Diagnostic, Referral Agency:

□ CTS □ STD Clinic
□ Other, specify

□ Adult HIV Clinic
□ Other, specify

*Provider Name

*Provider Phone (

Zip Code

□ Emergency Room
□ Laboratory □ Corrections □ Unknown
□ Other, specify
Other Facility:

*Specialty

)

Patient History (respond to all questions) (record all dates as mm/dd/yyyy) □ Pediatric risk (please enter in Comments)
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
Sex with male

□ Yes □ No □ Unknown

Sex with female

□ Yes □ No □ Unknown

Injected non-prescription drugs

□ Yes □ No □ Unknown

Received clotting factor for hemophilia/
coagulation disorder

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

/

/

□ Yes □ No □ Unknown

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 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

/

Received transplant of tissue/organs or artificial insemination
Worked in a healthcare or clinical laboratory setting

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

If occupational exposure is being investigated or considered as primary mode of exposure, specify occupation and setting:
Other documented risk (please include detail in Comments section)

□ Yes □ No □ Unknown

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.

(Page 2 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—

Laboratory Data (record additional tests in Comments section) (record all dates as mm/dd/yyyy)
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
RAPID TEST (check if rapid): □ Collection Date:
_/
Manufacturer: ________________________________________________
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): □ Collection Date:
_/
Manufacturer: ________________________________________________
TEST 3: □ 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): □ Collection Date:
_/
Manufacturer: ________________________________________________
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) □ Indeterminate
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
Collection Date:
/
/
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:
/
/
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 Copies/mL:
Log:
Collection Date:
/
TEST 2: □ HIV-1 RNA/DNA NAAT (Quantitative viral load)
RESULT: □ Detectable □ Undetectable Copies/mL:
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:

/

/

Other CD4 result: CD4 count:
Documentation of Tests

cells/µL CD4 percentage:

% Collection Date:

/

/

Complete only if none of the following was positive: HIV-1 Western blot, IFA, culture, p24 Ag test, viral load, or qualitative NAAT [RNA or DNA]:
Did documented laboratory test results meet approved HIV diagnostic algorithm criteria? □ Yes □ No □ Unknown
If YES, provide date (specimen collection date if known) of earliest positive test for this algorithm:
If HIV laboratory tests were not documented, is HIV diagnosis documented by a physician?
If YES, provide date of documentation by physician:

/

/

/

________

□ Yes □ No □ Unknown

/

Date of last documented negative HIV test (before HIV diagnosis date): :

___ / ____ / ______ Specify type of test: ______________________________________

Clinical (record all dates as mm/dd/yyyy)
Date

Date

Date

Candidiasis, bronchi,
trachea, or lungs

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

M. tuberculosis,
pulmonary†

Candidiasis,
esophageal

Histoplasmosis,
disseminated or
extrapulmonary

M. tuberculosis,
disseminated or
extrapulmonary†

Carcinoma, invasive
cervical

Isosporiasis, chronic
intestinal (>1 mo. duration)

Mycobacterium, of
other/unidentified
species, disseminated
or extrapulmonary

Coccidioidomycosis,
disseminated or
extrapulmonary

Kaposi’s sarcoma

Pneumocystis
pneumonia

Cryptococcosis,
extrapulmonary

Lymphoma, Burkitt’s (or
equivalent)

Pneumonia,
recurrent, in 12 mo.
period

Cryptosporidiosis,
chronic intestinal (>1
mo. duration)

Lymphoma, immunoblastic
(or equivalent)

Progressive
multifocal
leukoencephalopathy

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

Lymphoma, primary in
brain

Salmonella
septicemia, recurrent

Cytomegalovirus
retinitis (with loss of
vision)

Mycobacterium avium
complex or M. kansasii,
disseminated or
extrapulmonary

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

HIV encephalopathy

Wasting syndrome
due to HIV

†

If TB selected above, indicate RVCT Case Number:

(Page 3 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—

Treatment/Services Referrals (record all dates as mm/dd/yyyy)
Has this patient been informed of his/her HIV infection?
□ Yes □ No □ Unknown

This patient’s partners will be notified about their HIV exposure and counseled by:
□ 1-Health Dept □ 2-Physician/Provider □ 3-Patient □ 9-Unknown

For Female Patient
This patient is receiving or has been referred for gynecological or
obstetrical services: □ Yes □ No □ Unknown

Is this patient currently pregnant?
□ Yes □ No □ Unknown

Has this patient delivered live-born infants?
□ Yes □ No □ Unknown

For Children of Patient (record most recent birth in these boxes; record additional or multiple births in the Comments section)
*Child’s Name

Child Soundex

Child’s Date of Birth

*Child’s Coded ID

Child’s State Number

Hospital of Birth (if child was born at home, enter “home birth” for hospital name)
Hospital Name

*Phone

*Street Address

*Zip Code

City

County

State/Country

HIV Testing and Antiretroviral Use History (if required by Health Department) (record all dates as mm/dd/yyyy)
Main source of testing and treatment history information (select one)
□ Patient Interview □ Medical Record Review □ Provider Report □ NHM&E/PEMS
Ever had previous positive HIV test?

□ Yes □ No □ Refused □ Don’t Know/Unknown

Ever had a negative HIV test? □ Yes

□ No □ Refused □ Don’t Know/Unknown

Dates ARVs taken

/

/

*Comments

*Local / Optional Fields

(Page 4 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—

/

Date of last negative HIV test (If date is from
a lab test with test type, enter in Lab Data section)

□ Refused

□ Yes □ No □ Refused □ Don’t Know/Unknown

Date first began:

/

Date of first positive HIV test

Number of negative HIV tests within 24 months before first positive test #
Ever taken any antiretrovirals (ARVs)?

Date patient reported information

□ Other

□ Don’t Know/Unknown

If Yes, ARV medications:

Date of last use:

/

/

/

/
/

/