Perinatal HIV Exposure Reporting (PHER) Form

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

National HIV Surveillance System (NHSS)

Attachment 3d.
Supplemental Surveillance Activity 3
Perinatal HIV Exposure Reporting (PHER)

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 30329; ATTN: PRA (0920-0573).

Perinatal HIV Exposure Reporting (PHER)

U.S. Department of Health
& Human Services

Infant’s State Number ________________

Mother’s State Number ________________

Infant’s City Number ________________

Mother’s City Number ________________

Centers for Disease Control
and Prevention

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

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(s) performed before birth, but closest to date of delivery or admission to labor and delivery)
Yes Date (mm/dd/yyyy)
No
Not documented
Record not available
Group B strep
__ __/__ __/__ __ __ __

□
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __

Hepatitis B (HBsAg)
Rubella
Syphilis

□
□
□
□

□
□
□
□

□
□
□
□

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 (mm/dd/yyyy)

□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __
□ __ __/__ __/__ __ __ __

6. Mother’s reproductive history

No

□
□
□
□
□
□
□
□
□
□

Not documented

□
□
□
□
□
□
□
□
□
□

Record not available

□
□
□
□
□
□
□
□
□
□

Unknown

□
□
□
□
□
□
□
□
□
□

_________ 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 below)

State
Number

City
Number

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
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.
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).

Page 1 of 4

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

□ Yes □ No (Go to 9) □ 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
□ Cocaine
□ Amphetamines
□ Crack cocaine
□ Barbiturates
□ Hallucinogens
□ Benzodiazepines □ Heroin
□ Yes, negative result
□ No
□ Toxicology screen not documented

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

□ Opiates
□ Other (Specify) _________________
□ Specific drug(s) not documented

10. Was a toxicology screen done on the infant at birth?

□ Yes, positive result (Check all that apply)
□ Alcohol
□ Cocaine
□ Amphetamines
□ Crack cocaine
□ Barbiturates
□ Hallucinogens
□ Benzodiazepines □ 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
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 (Go to 13)
Drug name

Drug
refused

i. _________________________
ii. _________________________
iii. _________________________
iv. _________________________
v. _________________________
vi. _________________________

□
□
□
□
□
□

Date drug started
(mm/dd/yyyy)
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __

Gestational age
Drug stopped
drug started
Yes No ND
(weeks; round down)
______________
______________
______________
______________
______________
______________

□
□
□
□
□
□

□
□
□
□
□
□

□
□
□
□
□
□

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

Stop codes
(See list on
p. 4)

__ __/__ __/__ __ __ __ __________
__ __/__ __/__ __ __ __ __________
__ __/__ __/__ __ __ __ __________
__ __/__ __/__ __ __ __ __________
__ __/__ __/__ __ __ __ __________
__ __/__ __/__ __ __ __ __________

(After completing table, go to 13)

12a. If no antiretroviral drug was prescribed during pregnancy, check reason.
□ No prenatal care
□ Mother known to be HIV-negative during pregnancy
□ Not documented
□ Unknown
□ HIV serostatus of mother unknown
□ Mother refused
□ Other (Specify) ________________
13. Was mother’s HIV serostatus noted in her labor and delivery records?

□ Yes, HIV-positive

Page 2 of 4

□ Yes, HIV-negative

□ No

□ Record not available □ Unknown

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

□ Yes (Complete table) □ No (Go to 14a) □ Not documented (Go to 15) □ Record not available (Go to 15) □ Unknown (Go to 15)
Drug name

Drug
refused

Date received
(mm/dd/yyyy)

□
□
□
□
□
□

i. _________________________
ii. _________________________
iii. _________________________
iv. _________________________
v. _________________________
vi. _________________________

Time received
(See military time)
_______ : _______

__ __/__ __/__ __ __ __

_______ : _______

__ __/__ __/__ __ __ __

_______ : _______

__ __/__ __/__ __ __ __

_______ : _______

__ __/__ __/__ __ __ __

_______ : _______

__ __/__ __/__ __ __ __

_______ : _______

__ __/__ __/__ __ __ __

(After completing the table, go to 15)

Oral

□
□
□
□
□
□

Type of administration
IV
Not documented

□
□
□
□
□
□

□
□
□
□
□
□

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

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

□ Precipitous delivery/STAT

□ HIV serostatus of mother

Cesarean delivery

unknown

□ Prescribed but not administered □ Birth not in hospital
15. Was mother referred for HIV care after delivery?

□ Yes

□ No (Go to 17)

□ Not documented (Go to 17)

□ Mother tested HIV- □ Other (Specify)
negative during
pregnancy

□ Mother refused

_________________________

□ Not documented
□ Unknown

□ Record not available (Go to 17) □ Unknown

16. If yes, indicate mother’s first CD4 result or first viral load result after discharge from hospital
(up to 6 months after discharge).

16a. CD4 result

16b. Viral load result
Result in copies/mL

__ __ __ __

________________

__ __

17. Birth information

□ Not done □ Not available

Result
Unit
Date blood drawn
(mm/dd/yyyy)
cells/µL

__ __/__ __/__ __ __ __

%

__ __/__ __/__ __ __ __

□ Not done □ Not available
Result in logs
Date blood drawn
(mm/dd/yyyy)
_____________

__ __/__ __/__ __ __ __

□ Birth not in hospital □ Record not available
Time
(See military
time)

Date
(mm/dd/yyyy)

Onset of labor

__ __:__ __

__ __/__ __/__ __ __ __

Admission to labor
and delivery

__ __:__ __

__ __/__ __/__ __ __ __

Time
(See military
time)

Date
(mm/dd/yyyy)

Rupture of membranes

__ __:__ __

__ __/__ __/__ __ __ __

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 (e.g., 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

Page 3 of 4

20. Were antiretroviral drugs prescribed for the child?

□ Yes (Complete table) □ No (Go to 20a) □ Not documented □ Record not available □ Unknown
Drug name

i. _______________________
ii. _______________________
iii. _______________________
iv. _______________________
v. _______________________
vi. _______________________

Drug
refused

Date drug started
(mm/dd/yyyy)

□
□
□
□
□
□

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

Time started
Drug stopped
(See military Yes No ND UNK
time)

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

_____ : _____
_____ : _____
_____ : _____
_____ : _____
_____ : _____
_____ : _____

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

□ □
□ □
□ □
□ □
□ □
□ □

□
□
□
□
□
□

□
□
□
□
□
□

__________
__________
__________
__________
__________
__________

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

20a. If no antiretroviral drug was prescribed, indicate reason.
□ HIV serostatus of mother unknown
□ Other (Specify) __________________________________________
□ Mother known to be HIV-negative during pregnancy
□ Not documented

□ Mother refused

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
ART
ND
PCP
PID
STAT

antiretroviral therapy
not documented
Pneumocystis jirovecii pneumonia [jirovecii is now preferred to carinii; abbreviation is the same]
pelvic inflammatory disease
immediately (statim)

Comments
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.

Page 4 of 4