Form 0920-0573 Final Att-3e PHER Form (2)

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

Perinatal HIV Exposure Reporting Data Collection Form

29 October 2012

1

Form Approved
OMB No. 0920-0573
Expiration Date XX/XX/XXXX
Perinatal HIV Exposure Reporting Data Collection Form
for the National HIV Surveillance System (NHSS)

Perinatal HIV Exposure Reporting Data Collection Form
Public reporting burden of this collection of information is
estimated to average 30 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/ATSDR Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; Attn: PRA (0920-0573)

2

Infant State No. _____________________________

U.S. Department of Health
& Human Services
Centers for Disease Control
and Prevention

Pediatric HIV Exposure Reporting (PHER)
Form Approved OMB No. XXXXX Exp. Date XXXXXX

1.

If information on the mother is not available, was the child adopted, or in foster care?

 Yes  No  Not applicable

2. Records abstracted
(1 = Abstracted, 2 = Attempted—record not available, 3 = Not abstracted, 4 = Attempted—will try again)
_____ Prenatal care records

_____ Pediatric medical records (non-HIV clinic or provider)

_____ Maternal HIV clinic records

_____ Birth certificate

_____ Labor and delivery records

_____ Death certificate

_____ Pediatric birth records

_____ Health department records

_____ Pediatric HIV medical records

_____ Other (Specify.) ________________________________________________________

3. Weeks’ gestation at first prenatal care visit
__ __ weeks

4. Was the mother screened for any of the following during pregnancy?
(Check test performed before birth, but closest to date of delivery or admission to labor and delivery.)
Yes
Group B strep
Hepatitis B (HBsAg)
Rubella
Syphilis






Date (mm/dd/yyyy)

__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __

No

Not documented











Record not available Unknown











5. Diagnosis (for the mother) of the following conditions during this pregnancy or at the time of labor and delivery
(See Instructions for Data Abstraction for definitions.)
Yes
Bacterial vaginosis
Chlamydia trachomatis infection
Genital herpes
Gonorrhea
Group B strep
Hepatitis B (HbsAg+)
Hepatitis C
PID
Syphilis
Trichomoniasis












Date of diagnosis
(mm/dd/yyyy)

__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/_ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __

No












Not documented Record not available Unknown


































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).
Public reporting burden of this collection of information is estimated to average 30 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 completed form to this address.

05/2012

Page 1 of 5

Infant State No. _____________________________
6. Mother's reproductive history
___________ No. of previous pregnancies

_________ No. of previous miscarriages or stillbirths

___________ No. of previous live births

_________ No. of previous induced abortions or ______ Total No. of previous abortions

7. Complete the chart for all siblings.
Date of birth
(mm/dd/yyyy)

Age
(yrs: mos as of mm/yyyy)

HIV serostatus
(See list.)

State No.

City No.

Sib 1

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

Sib 2

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

Sib 3

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

Sib 4

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

HIV serostatus: 1 = Infected, 2 = Not infected, 3 = Indeterminate, 9 = Not documented U=Unknown

8. Was substance use during pregnancy noted in the medical or social work records?

 Yes  No (Go to 10.)  Record not available (Go to 9.)

 Unknown

8a. If yes, indicate which substances were used during pregnancy. (Check all that apply.)

 Alcohol
 Amphetamines
 Barbiturates
 Benzodiazepines

 Cocaine
 Crack cocaine
 Hallucinogens
 Heroin

 Marijuana (cannabis, THC, cannabinoids)
 Methadone
 Methamphetamines
 Nicotine (any tobacco product)

 Opiates
 Other (Specify.)
______________________________

 Specific drug(s) not documented

8b. If substances used, were any injected?

 Yes  No  Not documented  Unknown

Specify injected substance(s). __________________________________________

9. Was a toxicology screen done on the mother (either during pregnancy or at the time of delivery)?

 Yes, positive result (Check all that apply.)
 Alcohol
 Amphetamines
 Barbiturates
 Benzodiazepines

 Cocaine
 Crack cocaine
 Hallucinogens
 Heroin

 Marijuana (cannabis, THC, cannabinoids)
 Methadone
 Methamphetamines
 Nicotine (any tobacco product)

 Opiates
 Other (Specify.)
____________________________

 Specific drug(s) not documented

 Yes, negative result  No  Toxicology screen not documented
10. Was a toxicology screen done on the infant at birth?

 Yes, positive result (Check all that apply.)
 Alcohol
 Amphetamines
 Barbiturates
 Benzodiazepines

 Cocaine
 Crack cocaine
 Hallucinogens
 Heroin

 Marijuana (cannabis, THC, cannabinoids)
 Methadone
 Methamphetamines
 Nicotine (any tobacco product)

 Opiates
 Other (Specify.)
____________________________

 Specific drug(s) not documented

 Yes, negative result  No  Toxicology screen not documented

05/2012

Page 2 of 5

Infant State No. _____________________________

11. Was the mother's HIV serostatus noted in her prenatal care medical records?

 Yes, HIV-positive  Yes, HIV-negative  No  No prenatal care  Record not available  Unknown

12. Were antiretroviral drugs prescribed for the mother during this pregnancy?
 Yes (Complete table.)
 No (Go to 12a.)  Not documented (Go to 13.)
 Record not available (Go to 13.)  Unknown
Drug name
(See list on p. 8.)

Other
(specify)

Drug
refused

Date drug started
(mm/dd/yyyy)

Gestational age
drug started
(weeks; round down)

i. _______________ ___________



__ __/__ __/__ __ __ __

_____________

ii. _______________

__________



__ __/__ __/__ __ __ __

iii.________________

__________



iv.________________

__________

v.________________
vi.________________

 Treatment not indicated

Drug stopped
Yes No ND

Date stopped
(if yes in preceding column)
(mm/dd/yyyy)

Stop codes
(See list on
p. 8.)

  

__ __/__ __/__ __ __ __

_______

_____________

  

__ __/__ __/__ __ __ __

_______

__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

_______



__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

_______

__________



__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

_______

__________



__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

_______

(After completing table, go to 13.)

12a. If no antiretroviral drug was prescribed during pregnancy, check reason.

 No prenatal care
 HIV serostatus of mother unknown

 Mother known to be HIV-negative during pregnancy  Not documented  Unknown
 Mother refused
 Other (Specify.) __________________

13. Was mother's HIV serostatus noted in her labor and delivery records?

 Yes, HIV-positive

 Yes, HIV-negative

 No

 Record not available  Unknown

14. Did mother receive antiretroviral drugs during labor and delivery?

 Yes (Complete table.)
Drug Name
(See list.)

 No (Go to 14a.)

Other
(specify)

 Not documented (Go to 15.)

Drug
refused

 Record not available

(Go to 15.)

Date received
(mm/dd/yyyy)

Time received
(See military time.)

Oral

 Unknown

Type of administration
IV
Not documented

i. ___________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







ii. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







iii. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







iv. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







v. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







vi. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







(After completing table, go to 15.)

Military time: noon = 12:00; midnight = 00:00

14a. If no antiretroviral drug was received during labor and delivery, check reason.



Precipitous delivery/STAT
Cesarean delivery
Prescribed but not administered
Hospital did not have ARVs
available




 HIV serostatus of mother


unknown
Birth not in hospital

15. Was mother referred for HIV care after delivery?

 Yes

05/2012

 No (Go to 18.)

 Not documented (Go to 17.)

 Mother tested HIV-negative  Other (Specify.)
during pregnancy

 Mother refused

_______________________

 Not documented
 Unknown

 Record not available (Go to 17.)  Unknown
Page 3 of 5

Infant State No. _____________________________
16. If yes, indicate first CD4 result or first viral load after discharge from hospital (up to 6 months after discharge).

 Not done  Not available

16a. CD4 result

 Not done  Not available

16b. Viral load

Result

Unit

Date blood drawn
(mm/dd/yyyy)

Result in copies/mL

Result in logs

Date blood drawn
(mm/dd/yyyy)

__ __ __ __

cells/µL

__ __/__ __/__ __ __ __

_________________

____________

__ __/__ __/__ __ __ __

%

__ __/__ __/__ __ __ __

__ __

17. Birth information

 Birth not in hospital

 Record not available

Time

Date (mm/dd/yyyy)

Time

(See military time.)

Date (mm/dd/yyyy)

(See military time.)

Onset of labor

__ __:__ __

__ __/__ __/__ __ __ __

Rupture of membranes

__ __:__ __

__ __/__ __/__ __ __ __

Admission to labor and delivery

__ __:__ __

__ __/__ __/__ __ __ __

Delivery

__ __:__ __

__ __/__ __/__ __ __ __

Military time: noon = 12:00; midnight = 00:00

18. If Cesarean delivery, mark all the following indications that apply.

 HIV indication (high viral load)
 Previous Cesarean (repeat)
 Malpresentation (breech, transverse)
 Prolonged labor or failure to progress
 Mother’s or physician’s preference

 Fetal distress
 Placenta abruptia or p. previa
 Other (eg, herpes, disproportion)
Specify ________________________________

 Not specified

 Not applicable

19. Was mother's HIV serostatus noted on the child's birth record?

 No

 Yes, HIV-positive  Yes, HIV-negative  Record not available  Unknown
20. Were antiretroviral drugs prescribed for the child during the first 6 weeks of life?

 Yes (Complete table.)  No (Go to 20a.)  Not documented  Record not available  Unknown

Drug name
(See list on p. 8.)

Other
(specify)

Drug
refused

Date drug started
(mm/dd/yyyy)

Time started
(See military
time.)

ART
Completed?
Yes No ND UNK

Stop date
(if therapy not completed)
(mm/dd/yyyy)

Stop codes
(See list on
p. 8.)

i._________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

ii.________________ _____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

iii.________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

iv.________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

v.________________ _____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

vi.________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

Military time: noon = 12:00; midnight = 00:00

20a. If no antiretroviral drug was prescribed during the first 6 weeks of life, indicate reason.

 HIV serostatus of mother unknown
 Mother known to be HIV-negative during pregnancy
 Mother refused

05/2012

 Other (Specify.) _____________________________________________
 Unknown/Not documented

Page 4 of 5

Infant State No. _____________________________

Please include comments or clinical information you consider relevant to the overall understanding of this child's HIV exposure or
infection status. State the date and source of the information.

Antiretroviral drugs and stop codes
NNRTI
Delavirdine (Rescriptor)
Efavirenz (Sustiva)
Nevirapine (Viramune, NVP)
NRTI
Abacavir (Ziagen, ABC)
Combivir (AZT & 3TC)
Didanosine (ddI, Videx)
Emtriva (Emtricitabine or FTC)

NRTI (cont)
Epzicom (Abacavir/3TC, Kivexa)
Lamivudine (3TC, Epivir)
Stavudine (d4T, Zerit)
Trizivir (AZT & 3TC & Abacavir)
Truvada (Tenofovir DF/Emtricitabine)
®
Videx EC (Didanosine)
Viread (Tenofovir)
Zalcitabine (ddC, Hivid)
Zidovudine (AZT, Retrovir)

Protease inhibitor
Amprenavir (Agenerase)
Darunavir (Prezista)
Indinavir (Crixivan)
Kaletra (Lopinavir, Ritonavir)
Lexiva (Fosamprenavir)
Nelfinavir (Viracept)
Reyataz (Atazanavir or ATV)
Ritonavir (Norvir)
Saquinavir (Fortavase, Invirase)
Tipranavir (Aptivus)

Other
Adefovir dipivoxil (bis-POM,
PMEA, Preveon)
Atripla (Efavirenz & Tenofovir &
Emtricitabine)
Fuzeon (Enfuvirtide or T20)
Hydroxyurea (Droxia, Hydrea)
Intelence
Selzentry
Isentress
If an antiretroviral drug not
on this list, call CDC

Stop codes (2 codes allowed; if more, choose the 2 most important)
S1 = Adverse events (toxicity, lack of tolerance)
S2 = ART completed
S3 = Drug resistance detected
S4 = Poor adherence
S5 = Inadequate effectiveness

S6 = Strategic treatment interruption (planned drug holiday)
S7 = Drug interactions
S8 = Mother’s choice
S9 = Pregnancy
S10 = Child determined not to be HIV infected

S11 = Improving effectiveness
S12 = Improving convenience
S13 = Reason not indicated; unknown
S14 = Mother couldn’t afford drugs
Sxx = Other reason

List of abbreviations
ACTG
ART
EIA
HARS
HMO
ICD-9
ICD -10
IFA
ND
NNRTI

AIDS Clinical Trials Group
antiretroviral therapy
enzyme immunoassay
HIV/AIDS Reporting System
health maintenance organization
International Classification of Diseases, Ninth Revision
International Classification of Diseases, Tenth Revision
immunofluorescent assay
not documented
nonnucleoside reverse transcriptase inhibitor

05/2012

NRTI
NRR
OB-GYN
PCP
PI
PID
STAT
WB

nucleoside reverse transcriptase inhibitor
no risk factor reported
obstetric-gynecologic or obstetrician-gynecologist
Pneumocystis jirovecii pneumonia [jirovecii is now preferred to carinii;
abbreviation is the same]
protease inhibitor
pelvic inflammatory disease
immediately (statim)
Western blot

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