Pediatric HIV/AIDS Confidential Case Report

Attachment 3 (b)
Adult and Pediatric HIV/AIDS Confidential Case Reports
for National HIV/AIDS Surveillance OMB No. 0920-0573

Pediatric HIV/AIDS Confidential Case Report Form

1

Form Approved
OMB No. 0920-0573
Expiration Date XX/XX/20XX
Adult and Pediatric HIV/AIDS Confidential Case Reports
for National HIV/AIDS Surveillance
Pediatric HIV/AIDS Confidential Case Report Form

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/ATSDR Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; Attn: OMB-PRA (0920-0573)

2

I. STATE/LOCAL USE ONLY

Phone No.:(

Patient's Name:
(Last, First, M.I.)

Address:

City:

County:

PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT

U.S. DEPARTMENT OF HEALTH
& HUMAN SERVICES

(Patients <13 years of age at time of diagnosis)

Centers for Disease Control
and Prevention

II. HEALTH DEPARTMENT USE ONLY

DATE FORM COMPLETED:
Day

State:

– Patient identifier information is not transmitted to CDC! –

RETURN TO STATE/LOCAL HEALTH DEPARTMENT

Mo.

)
Zip
Code:

Yr.

SOUNDEX
CODE:

REPORT
STATUS:
New
1 Report
2 Update

REPORT SOURCE:

Form Approved OMB No. 0920-0573 Exp Date 2/28/2010

REPORTING HEALTH DEPARTMENT:

State
Patient No.:

State:
City/
County:

City/County
Patient No.:

III. DEMOGRAPHIC INFORMATION
DIAGNOSTIC STATUS AT REPORT:
(check one)
DATE OF BIRTH:

3

Perinatally HIV Exposed

5

AIDS

4

Confirmed HIV Infection (not AIDS)

6

Seroreverter

AGE AT DIAGNOSIS:
Years

Mo.

Day

Yr.

Was reason for initial
HIV evaluation due to
clinical signs and
symptoms?
Yes No Unk.
1

0

CURRENT
STATUS:

HIV Infection
(not AIDS) ...

1

Alive

2

Dead

AIDS ............

9

Unk.

SEX:

9

Months

ETHNICITY:
(select one)

Male
Female

2

Yr.

Mo.

4

Native Hawaiian or
Other Pacific Islander

2

5

White

3

Asian

1 U.S.

7

U.S. Dependencies and Possessions (including Puerto Rico)
(specify):

8 Other

9 Unk

Black or African American

RESIDENCE AT DIAGNOSIS:

9 Unk.

(specify):

State/
Country:

County:

Yr.

COUNTRY OF BIRTH:

1 American Indian/

Alaska Native

Hispanic
Hispanic
2 Not
or Latino
9 Unk.

City:

Day

Yr.

DATE OF INITIAL
EVALUATION FOR
HIV INFECTION:

STATE/TERRITORY
OF DEATH:

RACE: (select one or more)

1
1

DATE OF DEATH:
Mo.

Mo.

DATE OF LAST MEDICAL EVALUATION:

Zip
Code:

IV. FACILITY OF DIAGNOSIS
Facility
Name:

State/
Country:

City:

FACILITY SETTING (check one)
1 Public

2 Private

3 Federal

FACILITY TYPE (check one)
9 Unk.

01 Physician, HMO

31 Hospital, Inpatient

88 Other (specify):

V. PATIENT/MATERNAL HISTORY (Respond to ALL categories)

• Child’s biologic mother’s HIV Infection Status: (check one)
1

Refused HIV testing

2

Known to be uninfected after this child’s birth

9

HIV status unknown

Diagnosed with HIV Infection/AIDS:
3

Before this child’s pregnancy

5

At time of delivery

7

After the child’s birth

4

During this child’s pregnancy

6

Before child’s birth, exact period unknown

8

HIV-infected, unknown when diagnosed

Mo.

Yr.

• Mother was counseled about

• Date of mother’s first positive HIV confirmatory test: .....................
After 1977, this child’s biologic mother had:

Yes
• Injected nonprescription drugs .......................................................... 1

No

Unk.

0

9

• HETEROSEXUAL relations with:
- Intravenous/injection drug user ..................................................... 1

0

9

- Bisexual male ................................................................................ 1

0

9

- Male with hemophilia/coagulation disorder ................................... 1

0

9

- Transfusion recipient with documented HIV infection ................... 1

0

9

- Transplant recipient with documented HIV infection .................... 1

0

9

- Male with AIDS or documented HIV infection, risk not specified .. 1

0

9

Yes
HIV testing during this pregnancy, labor or delivery? ................. 1

No

Unk.

0

9

Before the diagnosis of HIV Infection/AIDS, this child had:

No

Unk.

0

9

Yes
• Received clotting factor for hemophilia/coagulation disorder ........... 1

(specify
1 Factor VIII (Hemophilia A)
2 Factor IX (Hemophilia B)
disorder):
8 Other (specify): _____________________________________________
• Received transfusion of blood/blood components
(other than clotting factor) ................................................................ 1

0

9

• Received transplant of tissue/organs .............................................. 1

0

9

• Sexual contact with a male ............................................................. 1

0

9

• Sexual contact with a female .......................................................... 1

0

9

Mo.

First:

Yr.

Mo.

Yr.

Last:

• Received transfusion of blood/blood components
(other than clotting factor) ................................................................ 1

0

9

• Injected nonprescription drugs ........................................................ 1

0

9

• Received transplant of tissue/organs or artificial insemination ......... 1

0

9

• Other (Alert State/City NIR Coordinator) ........................................ 1

0

9

CDC 50.42B Rev. 03/2007 (Page 1 of 4)

– PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT –

VI. STATE/LOCAL USE ONLY

Phone No.: (

Physician's Name:
(Last, First, M.I.)

Medical
Record No.

)

Person
Completing Form:

Hospital/Facility:

Phone No.: (

)

– Physician identifier information is not transmitted to CDC! –

VII. LABORATORY DATA
1. HIV ANTIBODY TESTS AT DIAGNOSIS: (Record all tests, include earliest positive)

Positive

Negative

Indeterminate

Not
Done

• HIV–1 EIA ..........................................................................................................................................................

1

0

–

9

• HIV–1 EIA ..........................................................................................................................................................

1

0

–

9

• HIV–1/HIV–2 combination EIA ..........................................................................................................................

1

0

–

9

• HIV–1/HIV–2 combination EIA ..........................................................................................................................

1

0

–

9

• HIV–1 Western blot/IFA .....................................................................................................................................

1

0

8

9

• HIV–1 Western blot/IFA .....................................................................................................................................

1

0

8

9

• Other HIV antibody test (specify): ___________________________________________________________

1

0

8

9

2. HIV DETECTION TESTS:
(Record all tests, include earliest positive)

Not
Positive Negative Done

TEST DATE
Mo.
Yr.

TEST DATE
Mo.
Yr.

• HIV DNA PCR ..............................................

1

0

9

• HIV culture ....................................................

1

0

9

• HIV DNA PCR ..............................................

1

0

9

• HIV culture ....................................................

1

0

9

• HIV RNA PCR ..............................................

1

0

9

• HIV antigen test ............................................

1

0

9

• HIV RNA PCR ..............................................

1

0

9

• HIV antigen test ............................................

1

0

9

• Other, specify ________________________

1

0

9

*Type: 11. NASBA (Organon)

3. HIV VIRAL LOAD TEST: (Record all tests, include earliest detectable)
Test type*

Detectable
Yes

No

1

0

Test Date

Copies/ml

Mo.

Yr.

4. IMMUNOLOGIC LAB TESTS: (At or closest to current diagnostic status)
Mo.

• CD4 Count ......................................
• CD4 Count ......................................

,
,

Yr.

TEST DATE
Mo.
Yr.

Not
Positive Negative Done

Test type*

12. RT-PCR (Roche)

Detectable
Yes

No

1

0

13. bDNA(Chiron)

18. Other

Test Date

Copies/ml

Mo.

Yr.

5. If HIV tests were not positive or were not done, or the patient is less
Yes No Unk.
than 18 months of age, does this patient have an immunodeficiency
0
9
that would disqualify him/her from the AIDS case definition? .............. 1

cells/µL
6. If laboratory tests were not documented,
is patient confirmed by a physician as:

cells/µL

Date of Documentation
Yes

No

Unk.

0

9

0

9

• CD4 Percent ...................................................

%

• HIV-infected ..........................................

1

• CD4 Percent ...................................................

%

• Not HIV-infected ...................................

1

Mo.

Yr.

VIII. CLINICAL STATUS
AIDS INDICATOR DISEASES

Initial Diagnosis
Def.

Pres.

1

NA

Candidiasis, bronchi, trachea, or lungs

1

NA

Candidiasis, esophageal

1

2

Coccidioidomycosis, disseminated or
extrapulmonary

1

Cryptococcosis, extrapulmonary

Initial Date

Mo.

Yr.

Initial Diagnosis

AIDS INDICATOR DISEASES

Def.

Pres.

Kaposi's sarcoma

1

2

Lymphoid interstitial pneumonia and/or
pulmonary lymphoid hyperplasia

1

2

Lymphoma, Burkitt's (or equivalent term)

1

NA

NA

Lymphoma, immunoblastic (or equivalent term)

1

NA

1

NA

Lymphoma, primary in brain

1

NA

Cryptosporidiosis, chronic intestinal
(>1 mo. duration)

1

NA

Mycobacterium avium complex or M.kansasii,
disseminated or extrapulmonary

1

2

Cytomegalovirus disease (other than in liver,
spleen, or nodes) onset at >1 mo. of age

1

NA

M. tuberculosis, disseminated or extrapulmonary*

1

2

Cytomegalovirus retinitis (with loss of vision)

1

2

Mycobacterium, of other species or unidentified
species, disseminated or extrapulmonary

1

2

HIV encephalopathy

1

NA

Pneumocystis carinii pneumonia

1

2

Herpes simplex: chronic ulcer(s) (>1 mo. duration); or bronchitis, pneumonitis or esophagitis, onset at >1 mo. of age

1

NA

Progressive multifocal leukoencephalopathy

1

NA

Histoplasmosis, disseminated or extrapulmonary

1

NA

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

1

2

Isosporiasis, chronic intestinal (>1 mo. duration)

1

NA

Wasting syndrome due to HIV

1

NA

Bacterial infections, multiple or recurrent
(including Salmonella septicemia)

Def. = definitive diagnosis
Has this child been diagnosed
with pulmonary tuberculosis?*

1 Yes

CDC 50.42B Rev. 03/2007 (Page 2 of 4)

0 No

9 Unk.

Pres. = presumptive diagnosis

If yes, initial
diagnosis and date: 1 Definitive

Mo.
2 Presumptive

– PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT –

Yr.

*RVCT CASE NO.:

Initial Date

Mo.

Yr.

IX. BIRTH HISTORY (for PERINATAL cases only)
Birth history was available for this child:

Yes

1

0

No

9

If No or Unknown, proceed to Section X.

Unk.

HOSPITAL AT BIRTH:
Hospital:__________________________________________ City: _____________________________ State: ____________________ Country: _______________________
RESIDENCE AT BIRTH:
City:
BIRTH:

BIRTHWEIGHT:
(enter lbs/oz OR grams)
lbs.

oz

grams

Type: ....

1 Single

2 Twin

Delivery: ............. 1 Vaginal

Birth Defects: ....

3 >2

4 Caesarean, unk. type

9 Unk.

1 Yes

9 Unk.

0 No

zidovudine (ZDV, AZT) Refused Yes
8
1
during pregnancy?

• If yes, what week of

Maternal Date of Birth
Mo.

Day

3 Non-elective Caesarean

•

No
0

• Did mother receive

Unk.

zidovudine (ZDV, AZT) Refused Yes
8
1
during labor/delivery?

9

• Did mother receive

zidovudine (ZDV, AZT)
prior to this pregnancy?

99 = Unk.

Month of pregnancy
prenatal care began:

Full term

2

Premature
Total number of
prenatal care visits:

99 = Unk.

mos.
99 = Unk.
00 = None

99 = Unk.
00 = None

• Did mother receive any other

No

Unk.

0

9

Yes No Unk.
Anti-retroviral medication
1
0
9
during pregnancy?
If yes, specify: _________________________________

• Did mother receive any other

Yes

No

Unk.

1

0

9

Yes No Unk.
Anti-retroviral medication
1
0
9
during labor/delivery?
If yes, specify: _________________________________

Maternal State Patient No.

Maternal Soundex:

Yr.

PRENATAL CARE:

1

Weeks

Code:

Weeks:

pregnancy was zidovudine
(ZDV, AZT) started?

NEONATAL
STATUS:

9 Unk.

2 Elective Caesarean

Specify
type(s):

• Did mother receive

Zip
Code:

State/
Country:

County:

Birthplace of Biologic Mother:
1 U.S.
7 U.S. Dependencies and Possessions (including Puerto Rico) (specify): ____________________________________________________
8

Other (specify): ___________________________________________________

9

Unk.

X. TREATMENT/SERVICES REFERRALS
This child received or is receiving:
Yes
• Neonatal zidovudine (ZDV, AZT)
for HIV prevention ............................................ 1
• Other neonatal anti-retroviral medication
for HIV prevention ............................................ 1

DATE STARTED
Mo.
Day
Yr.

No

Unk.

0

9

• Anti-retroviral therapy
for HIV treatment ...................

Yes

No

Unk.

1

0

9

0

9

• PCP prophylaxis .................... 1

0

9

DATE STARTED
Mo.
Day
Yr.

If yes, specify: __________________________________________________________
Was child breastfed?
Yes

No

Unk.

1

0

9

This child’s medical treatment is primarily reimbursed by:

This child has been enrolled at:
Clinical Trial

Clinic

1

Medicaid

4

Other Public Funding

1 NIH-sponsored

2 Other

1 HRSA-sponsored

2 Other

2

Private insurance/HMO

7

Clinical trial/government program

3 None

9 Unk.

3 None

9 Unk.

3

No coverage

9

Unk.

This child’s primary caretaker is:
1

Biologic
parent(s)

2

Other
relative

3

Foster/Adoptive
parent, relative

4

Foster/Adoptive
parent, unrelated

7 Social service

agency

8 Other

(specify in Section XI.)

9 Unk.

XI. COMMENTS:

(XI. COMMENTS CONTINUED ON THE BACK)
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 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. 03/2007 (Page 3 of 4)

– PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT –

XI. COMMENTS (continued)

CDC 50.42B Rev. 03/2007 (Page 4 of 4)

– PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT –