Adult HIV Confidential Case Report Form 2015

Form Approved
OMB No. 0920-0573
Expiration Date: XX/XX/XXXX

National HIV Surveillance System (NHSS)

Attachment 3a.
Adult HIV 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30329; ATTN: PRA (0920-0573).

Patient Identification (record all dates as mm/dd/yyyy)
*First Name

*Middle Name

Alternate Name Type
(ex: Alias, Married)

*Last Name

*First Name

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

Address Type

*Phone
(
) ______________
*Medical Record Number

City

Last Name Soundex

*Middle Name

*Last Name

*Current Address, Street

County

Address Date
__ __ /__ __ /__ __ __ __
*ZIP Code

State/Country
*Other ID Type

* Number

Adult 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. XX/XX/XXXX

Health Department Use Only (record all dates as mm/dd/yyyy)
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
Inpatient:

□ Hospital
□ Other, specify ________________

State/Country
Outpatient: □ Private Physician’s Office

□ Adult HIV Clinic
□ Other, specify ______­­­__________

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

* ZIP Code

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

□ Other, specify

_____________

*Person Completing Form

Other Facility: □ Emergency Room

□ Laboratory □ Corrections □ Unknown
□ Other, specify _________________

*Phone (

) ______________________

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

□ Male □ Female □ Unknown

Country of Birth

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

Ethnicity

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)

(please specify) ______________________

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

□ 1-Alive □ 2-Dead

Current Gender Identity

□ US □ Other/US Dependency

Expanded Ethnicity

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

___________________

Expanded Race ________________________

Residence at Diagnosis (add additional addresses in Comments) (record all dates as mm/dd/yyyy)
Address Type
(Check all that apply to address below)

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

*Street Address
City

County

State/Country

Address Date
__ __ /__ __ /__ __ __ __
*ZIP Code

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 50.42A

Rev. 9/2015

(Page 1 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—

STATE/LOCAL USE ONLY
*Provider Name (Last, First, M.I.)
______________________________________________________

*Phone (

) __________________

Hospital/Facility
_____________________________________________________

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

(Check all that apply to facility below)

□ HIV

□ AIDS

□ Check if SAME as Facility Providing Information

Facility Name

*Phone (

) _______________________

*Street Address
City
Facility
Type

County

□ Hospital
□ Other, specify
Inpatient:

___________

*Provider Name

State/Country

Outpatient: □ Private Physician’s Office

□ Adult HIV Clinic
□ Other, specify ______­­­__________
*Provider Phone (

*ZIP Code

Screening, Diagnostic, Referral Agency:

□ CTS □ STD Clinic
□ Other, specify ________________

) _______________________

Other Facility: □ Emergency Room

□ Laboratory □ Corrections □ Unknown
□ Other, specify _________________

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
□ Yes □  No □  Unknown

Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments)
First date received __ __ /__ __ /__ __ __ __ Last date received __ __ /__ __ /__ __ __ __
Received transplant of tissue/organs or artificial insemination

□ Yes □  No □  Unknown

Worked in a healthcare or clinical laboratory setting

□ Yes □  No □  Unknown

If occupational exposure is being investigated or considered as primary mode of exposure, specify occupation and setting:
_________________________________________________________________________________________________

□ Yes □  No □  Unknown

Other documented risk (please include detail in Comments)

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. Information in CDC’s National HIV 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 50.42A

Rev. 9/2015

(Page 2 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—

Laboratory Data (record additional tests and tests not specified below in Comments) (record all dates as mm/dd/yyyy)
HIV Immunoassays (Non-differentiating)

□ HIV-1 IA □ HIV-1/2 IA □ HIV-1/2 Ag/Ab □ HIV-1 WB □ HIV-1 IFA □ HIV-2 IA □ HIV-2 WB

TEST 1:

Test Brand Name/Manufacturer:____________________________________________________________________________________________

□ Positive/Reactive □ Negative/Nonreactive □ Indeterminate
Collection Date: __ __ /__ __ /__ __ __ __
□ HIV-1 IA □ HIV-1/2 IA □ HIV-1/2 Ag/Ab □ HIV-1 WB □ HIV-1 IFA □ HIV-2 IA □ HIV-2 WB

RESULT:
TEST 2:

□ Rapid Test (check if rapid)

Test Brand Name/Manufacturer:____________________________________________________________________________________________

□ Positive/Reactive □ Negative/Nonreactive □ Indeterminate

RESULT:

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

□ Rapid Test (check if rapid)

HIV Immunoassays (Differentiating)

□ HIV-1/2 Type-differentiating (Differentiates between HIV-1 Ab and HIV-2 Ab)

Test Brand Name/Manufacturer:____________________________________________________________________________________________
RESULT:
□ HIV-1
□ HIV-2
□ Both (undifferentiated)
□ Neither (negative)
□ 
Indeterminate
Collection Date: __ __ /__ __ /__ __ __ __
□ Rapid Test (check if rapid)
□ HIV-1/2 Ag/Ab-differentiating (Differentiates between HIV Ag and HIV Ab)
Test Brand Name/Manufacturer:____________________________________________________________________________________________
RESULT:
□ Ag reactive
□ Ab reactive
□ Both (Ag and Ab reactive) □ Neither (negative)
□ Invalid/Indeterminate
Collection Date: __ __ /__ __ /__ __ __ __
□ Rapid Test (check if rapid)
□ HIV-1/2 Ag/Ab and Type-differentiating (Differentiates among HIV-1 Ag, HIV-1 Ab, HIV-2 Ab)
Test Brand Name/Manufacturer:____________________________________________________________________________________________
RESULT*: HIV-1 Ag
HIV-Ab
□ Reactive □ Nonreactive □ Not Reported
□ HIV-1 Reactive □ HIV-2 Reactive □ Both Reactive, Undifferentiated □ Both Nonreactive
Collection Date: __ __ /__ __ /__ __ __ __
*Select one result for HIV-1 Ag and one result for HIV Ab
HIV Detection Tests (Qualitative)

□ HIV-1 RNA/DNA NAAT (Qual) □ HIV-1 Culture □ HIV-2 RNA/DNA NAAT (Qual) □ HIV-2 Culture
□ Positive/Reactive □ Negative/Nonreactive □ Indeterminate Collection Date: __ __ /__ __ /__ __ __ __

TEST:
RESULT:

HIV Detection Tests (Quantitative viral load) Note: Include earliest test at or after diagnosis

□ HIV-1 RNA/DNA NAAT (Quantitative viral load) □ HIV-2 RNA/DNA NAAT (Quantitative viral load)
□ Detectable □ Undetectable Copies/mL: _________________ Log: ______________ Collection Date: __ __ /__ __ /__ __ __ __
□ HIV-1 RNA/DNA NAAT (Quantitative viral load) □ HIV-2RNA/DNA NAAT (Quantitative viral load)
□ Detectable □ Undetectable Copies/mL: _________________ Log: ______________ Collection Date: __ __ /__ __ /__ __ __ __

TEST 1:
RESULT:
TEST 2:
RESULT:

Immunologic Tests (CD4 count and percentage)
CD4 at or closest to diagnosis: 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: __________________________________cells/µL CD4 percentage: ____% Collection Date: __ __ /__ __ /__ __ __ __
Documentation of Tests
Did documented laboratory test results meet approved HIV diagnostic algorithm criteria?

□ Yes □ No

□ Unknown

If YES, provide specimen collection date of earliest positive test for this algorithm: __ __ /__ __ /__ __ __ __

Complete the above only if none of the following was positive: HIV-1 Western blot, IFA, culture, viral load, or qualitative NAAT [RNA or DNA]
If HIV laboratory tests were not documented, is HIV diagnosis documented by a physician?
If YES, provide date of diagnosis: __ __ /__ __ /__ __ __ __

□ Yes □ No

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

□ Unknown

Specify type of test: ____________________________________

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

Dx Date

Diagnosis

Dx Date

Diagnosis

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:

CDC 50.42A

Rev. 9/2015

(Page 3 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—

Dx Date

Treatment/Services Referrals (record all dates as mm/dd/yyyy)
This patient’s partners will be notified about their HIV exposure and counseled by:

Has this patient been informed of his/her HIV infection?
□ Yes □ No □ Unknown

□ 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 Comments)
*Child’s Name

Child’s Last Name
Soundex
Child’s State Number

*Child’s Coded ID
Facility Name of Birth (if child was born at home, enter “home birth”)
Facility Type

Inpatient:

Child’s Date of Birth

__ __ /__ __ /__ __ __ __

*Phone
(
) _______________________
*ZIP Code
Other Facility: □ Emergency Room

Outpatient:

□ Hospital
□ Other, specify ______­­­__________ □ Corrections □ Unknown
□ Other, specify ________________
□ Other, specify _________________

*Street Address

City

County

State/Country

HIV Antiretroviral Use History (record all dates as mm/dd/yyyy)
Main source of antiretroviral (ARV) use information (select one):
□ Patient Interview
□ Medical Record Review
□ Provider Report
Ever taken any ARVs?

□ NHM&E

Date patient reported information

□ Other

__ __ /__ __ /__ __ __ __

□ Yes □ No □ Unknown

If yes, reason for ARV use (select all that apply):

□ HIV Tx

ARV medications: ________________________________

Date began: __ __ /__ __ /__ __ __ __

Date of last use: __ __ /__ __ /__ __ __ __

□ PrEP

ARV medications: ________________________________

Date began: __ __ /__ __ /__ __ __ __

Date of last use: __ __ /__ __ /__ __ __ __

□ PEP

ARV medications: ________________________________

Date began: __ __ /__ __ /__ __ __ __

Date of last use: __ __ /__ __ /__ __ __ __

□ PMTCT

ARV medications: ________________________________

Date began: __ __ /__ __ /__ __ __ __

Date of last use: __ __ /__ __ /__ __ __ __

□ HBV Tx

ARV medications: ________________________________

Date began: __ __ /__ __ /__ __ __ __

Date of last use: __ __ /__ __ /__ __ __ __

Date began: __ __ /__ __ /__ __ __ __

Date of last use: __ __ /__ __ /__ __ __ __

□ Other __________________________________________________
ARV medications: ________________________________

HIV Testing History (record all dates as mm/dd/yyyy)
Main source of testing history information (select one):
□ Patient Interview
□ Medical Record Review
Ever had previous positive HIV test?
Ever had a negative HIV test?

□ Provider Report

□ NHM&E

□ Yes □ No □ Unknown

□ Yes □ No □ Unknown

□ Other

Date of first positive HIV test __ __ /__ __ /__ __ __ __
Date of last negative HIV test (If date is from

a lab test with test type, enter in Lab Data section)

Number of negative HIV tests within 24 months before first positive test # ­­­­­­­­­­­­­­­­­­­_____________

□ Unknown

Comments

*Local/Optional Fields

CDC 50.42A

Rev. 9/2015

(Page 4 of 4)

Date patient reported information

__ __ /__ __ /__ __ __ __

—ADULT HIV CONFIDENTIAL CASE REPORT—

__ __ /__ __ /__ __ __ __