Form 0920-0573 Pediatric HIV Confidential Case Report Form

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

Pediatric HIV Confidential Case Report Form

1

Patient Identification
*Patient Name

*First Name

*Middle Name

*Alternate Name Type
(ex Birth, Call Me)

*Last Name

*First Name

Address Type

□ Residential □

Facility
□ Foster Home
City

□ Homeless □ Postal □County
Shelter □ Temporary

*Middle Name

□ Correctional

Bad Address

Last Name Soundex
*Last Name

*Current Street Address

*Phone (

State/Country

*Medical Record Number

)

*ZIP Code

*Other ID Type:

Number:

Pediatric 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. XX/XX/XXXX

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

Outpatient: □ Private Physician’s Office

Inpatient:

Date Form Completed

/

State/Country

□ Pediatric HIV Clinic □ Other, specify

□ Pediatric Clinic

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
Date of Birth
Vital Status

/

/

Alias Date of Birth

□ 1-Alive □ 2-Dead

Date of Last Medical Evaluation
Ethnicity

Sex assigned at Birth
□ Male □ Female □ Unknown

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

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).
(Page 1 of 4)

—PEDIATRIC 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 □ 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

Inpatient:

□ Pediatric HIV Clinic □ Other, specify

*Provider Name

*Provider Phone (

□ Pediatric Clinic

Zip Code

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

*Specialty

)

Patient History (respond 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 non-prescription drugs

□ 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 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

(Page 2 of 4)

—PEDIATRIC 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)
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 of earliest positive test for this algorithm (specimen collection date if known):

□ Yes □ No □ Unknown
Not HIV-Infected □ Yes □ No □ Unknown
HIV-Infected

If laboratory tests were not documented,
is patient confirmed by a physician as:

/

/

_______

Date of documentation:

____________ / ___________ / __________

Date of documentation:

____________ / ___________ / __________

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

Date

Bacterial infection, multiple or recurrent (including
Salmonella septicemia)

Kaposi’s sarcoma

Candidiasis, bronchi, trachea, or lungs

Lymphoma, Burkitt’s (or equivalent)

Candidiasis, esophageal

Lymphoma, i mmunoblastic (or equivalent)

Coccidioidomycosis, disseminated or extrapulmonary

Lymphoma, primary in brain

Cryptococcosis, extrapulmonary

Mycobacterium avium complex or M. kansasii, disseminated

Cryptosporidiosis, chronic intestinal (>1 mo. duration)

M. tuberculosis, disseminated or extrapulmonary†

Cytomegalovirus disease (other than in liver, spleen,

Mycobacterium, of other/unidentified species, disseminated

or nodes)

or extrapulmonary

Cytomegalovirus retinitis (with loss of vision)

Pneumocystis pneumonia

HIV encephalopathy

Progressive multifocal leukoencephalopathy

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

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

Histoplasmosis, disseminated or extrapulmonary

Wasting syndrome due to HIV

or extrapulmonary

Isosporiasis, chronic intestinal (>1 mo. duration)
Has this child been
diagnosed with pulmonary
tuberculosis?

□ Yes □ No
□ Unknown

If Yes, initial diagnosis: □ Definitive
□ Unknown

□ Presumptive

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.
(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

Zip Code

)

City

County

State/Country

Birth History
Birth Weight
lbs

oz

grams

□ Yes □ No
□ Unknown
Neonatal Status □ 1-Full-term □ 2-Premature
□ Unknown
Birth Defects

Gestational Month
Prenatal Care began

Type □ 1-Single □ 2-Twin
Delivery
□ 3->2 □ 9-Unknown
If yes, please specify:

Neonatal Gestational Age in Weeks:

(00-None, 99-Unknown)

Did mother receive any Anti-retrovirals
(ARVs) prior to this pregnancy:
Did mother receive any ARVs
during pregnancy:
Did mother receive any ARVs
during labor/delivery?

□ 1-Vaginal □ 2-Elective Cesarean □ 3-Non-Elective Cesarean
□ 4-Cesarean, unknown type □ 9-Unknown

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

(99–Unknown)

Prenatal Care - Total number of prenatal
care visits:

(00-None, 99-Unknown)

If yes, please
specify all:
If yes, please
Specify all:
If yes, please
specify all:

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:

□ Yes □ No □ Unknown

Neonatal ARVs for HIV prevention:
If Yes, please specify: 1)
Anti-retroviral therapy for HIV treatment:

2)

□ Yes □ No □ Unknown

Date:

/

/

3)

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

(Page 4 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—