Pediatric HIV Confidential Case Report Form 2015

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

National HIV Surveillance System (NHSS)

Attachment 3b.
Pediatric 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: Birth, Call Me)

*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

Pediatric 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

□ Hospital
□ Other, specify _____________
Inpatient:

State/Country

Outpatient: □ Private Physician’s Office

□ Pediatric Clinic
□ Pediatric HIV Clinic □ Other, specify ____________­­­____­­___

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

*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

Sex assigned at Birth
□ Male □ Female □ Unknown

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

□ 1-Alive □ 2-Dead

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

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

Date of Last Medical Evaluation __ __ /__ __ /__ __ __ __
Ethnicity

Country of
Birth

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

□ Residence at

Perinatal Exposure

□ Residence at Pediatric □ Check if SAME as
Seroreverter

* Street Address
City

County

State/Country

Current Address

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 50.42B

Rev. 9/2015

(Page 1 of 4)

—PEDIATRIC 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 □ Perinatal Exposure □ 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

□ Pediatric Clinic
□ Pediatric HIV Clinic □ Other, specify _____________

Inpatient:

*Provider Name

*Provider Phone (

) ______________________

*ZIP Code
Other Facility: □ Emergency Room

□ Laboratory
□ Unknown □ Other, specify _________________
Specialty

Patient History (respond to all questions) (record all dates as mm/dd/yyyy)

□ Refused HIV testing □ Known to be uninfected after this child’s birth
□ Known HIV+ before pregnancy □ Known HIV+ during pregnancy
□ Known HIV+ sometime before birth □ Known HIV+ at delivery
□ Known HIV+ after child’s birth □ HIV+, time of diagnosis unknown □ 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
□ Yes □  No □  Unknown

Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments)
First date received ___ ___ / ___ ___ / ___ ___ ___ ___ Last date received ___ ___ / ___ ___ / ___ ___ ___ ___

□ 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: ___ ___ / ___ ___ / ___ ___ ___ ___

Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments)

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

First date received ___ ___ / ___ ___ / ___ ___ ___ ___ Last date received ___ ___ / ___ ___ / ___ ___ ___ ___
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)

□ Yes □  No □  Unknown

CDC 50.42B

Rev. 9/2015

(Page 2 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

Laboratory Data (record additional tests and tests not specified in Comments) (record all dates as mm/dd/yyyy)
HIV Immunoassays (Non-differentiating)
TEST 1:

□ 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 Brand Name/Manufacturer:____________________________________________________________________________________________

RESULT:
TEST 2:

□ 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

Test Brand Name/Manufacturer:____________________________________________________________________________________________

□ Rapid Test (check if rapid)

RESULT: □ Positive/Reactive □ Negative/Nonreactive □ Indeterminate
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)
TEST:

□ HIV-1 RNA/DNA NAAT (Qual) □ 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 at or after diagnosis
TEST 1:
RESULT:
TEST 2:
RESULT:

□ 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: __ __ /__ __ /__ __ __ __

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

HIV-Infected
Not HIV-Infected

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

Date of diagnosis: __ __ /__ __ /__ __ __ __
Date of diagnosis: __ __ /__ __ /__ __ __ __

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

Bacterial infection, multiple or recurrent
(including Salmonella septicemia)

Dx Date

Candidiasis, bronchi, trachea, or lungs

Diagnosis

HIV encephalopathy

Candidiasis, esophageal

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

Carcinoma, invasive cervical

Isosporiasis, chronic intestinal (>1 mo. duration)

Coccidioidomycosis, disseminated or
extrapulmonary
Cryptococcosis, extrapulmonary

Kaposi’s sarcoma
Lymphoid interstitial pneumonia and/or
pulmonary lymphoid hyperplasia
Lymphoma, Burkitt’s
(or equivalent)
Lymphoma, immunoblastic
(or equivalent)
Lymphoma, primary in brain

Cryptosporidiosis, chronic intestinal
(>1 mo. duration)
Cytomegalovirus disease
(other than in liver, spleen, or nodes)
Cytomegalovirus retinitis
(with loss of vision)
†

Dx Date

Diagnosis

Mycobacterium avium complex or M.
kansasii, disseminated or extrapulmonary
M. tuberculosis, pulmonary†
M. tuberculosis, disseminated or
extrapulmonary†
Mycobacterium, of other/unidentified
species, disseminated or extrapulmonary
Pneumocystis pneumonia
Pneumonia, recurrent in 12 mo. period
Progressive multifocal
leukoencephalopathy
Toxoplasmosis of brain, onset at >1 mo.
of age
Wasting syndrome due to HIV

If TB selected above, indicate RVCT Case Number:

CDC 50.42B

Rev. 9/2015

(Page 3 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

Dx Date

Birth History (for Perinatal Cases only)
Residence at Birth
Birth History Available

□ Yes □ No □ Unknown

□ Check if SAME as Current Address

* Street Address

City

County

State/Country

*ZIP Code

Facility of Birth

□ Check if SAME as Facility Providing Information
Facility Name of Birth (if child was born at home, enter “home birth”)
Facility Type
*Street Address

□ Hospital
□ Other, specify ________________

Outpatient:

Inpatient:

Birth History

) _____________

□ Other, specify ______­­­__________
City

Type □ 1-Single □ 2-Twin
□ 3->2 □ 9-Unknown

Birth Weight
______ lbs _______ oz ______ grams
Birth Defects

□ Yes □ No □ Unknown

Neonatal Status

□ 1-Full-term □ 2-Premature □ Unknown

Gestational Month
Prenatal Care Began

*Phone (

*ZIP Code

Other Facility: □ Emergency Room

□ Corrections □ Unknown
□ Other, specify _________________
County

Delivery

State/Country

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

If yes, please specify:
Neonatal Gestational Age in Weeks:

___________ (99–Unknown)

Prenatal Care – Total number of
____________
prenatal care visits:
(00-None, 99-Unknown)
If yes, please specify all:
Did mother receive any antiretrovirals (ARVs) prior to this pregnancy?
□ Yes □ No □ Refused □ Unknown
If yes, please specify all:
Did mother receive any ARVs during pregnancy?
□ Yes □ No □ Unknown
If yes, please specify all:
Did mother receive any ARVs during labor/delivery?
□ Yes □ No □ Unknown

Maternal Information
Maternal DOB

____________
(00-None, 99-Unknown)

Maternal Last Name 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:
Neonatal ARVs for HIV prevention: □ Yes

□ No □ Unknown

If Yes, please specify: 1)

2)

Anti-retroviral therapy for HIV treatment: □ Yes

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

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

3)

4)

5)

□ No □ Unknown
□ Yes □ No □ Unknown
Date began: __ __ /__ __ /__ __ __ __ Date of last use: __ __ /__ __ /__ __ __ __
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
Date began: __ __ /__ __ /__ __ __ __

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

PCP Prophylaxis:

Comments

*Local/Optional Fields

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 50.42B

Rev. 9/2015

(Page 4 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—