Pediatric Case Report Form

National HIV Surveillance System (NHSS)

Attachment 3b.
Pediatric HIV Confidential Case Report Form

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

*Middle Name

Alternate Name Type (example: Birth, Call Me)

*First Name

□ Bad address □ Correctional facility
□ Foster home □ Homeless □ Military □ Other
□ Postal □ Shelter □ Temporary
City

Last Name Soundex

*Middle Name

*Last Name

*Current Address, Street

Address Type □ Residential

*Phone
(
)
*Medical Record Number

*Last Name

County

Address Date
/
*ZIP Code

State/Country

*Other ID Type

*Number

Pediatric HIV Confidential Case Report Form

U.S. Department of Health
and Human Services

Centers for Disease Control
and Prevention (CDC)

(Patients aged <13 years at time of diagnosis) *Information NOT transmitted to CDC

Health Department Use Only (record all dates as mm/dd/yyyy)
Date Received at Health Department
/
/

Form approved OMB no. NNNN-NNNN Exp. MM/DD/YYYY

eHARS Document UID

Reporting Health Dept—City/County

/

State Number

City/County Number

Document Source

Surveillance Method

□ Active
Did this report initiate a new case investigation?
□ Yes □ No □ Unknown

□ Passive

□ Follow up

Report Medium
□ 1-Field visit □ 2-Mailed

□ Reabstraction

□ 3-Faxed

□ Unknown

□ 4-Phone

□ 5-Electronic transfer

□ 6-CD/disk

Facility Providing Information (record all dates as mm/dd/yyyy)
Facility Name

*Phone
(
)

*Street Address
City

County

Facility
Type

□ Hospital
□ Other, specify

State/Country

*ZIP Code

□ Private physician’s office □ Pediatric clinic
□ Pediatric HIV clinic □ Other, specify

Inpatient:

□ Emergency room □ Laboratory
□ Unknown □ Other, specify _____________________

Outpatient:

Date Form Completed

Other Facility:

*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
Date of Birth

/

Vital Status □ 1-Alive

Date of Last Medical Evaluation
Ethnicity

Alias Date of Birth

/
Date of Death

□ 2-Dead
/

/

/

Date of Initial Evaluation for HIV

/

(please specify)
/

State of Death

/

/

/

Expanded Ethnicity

□ Hispanic/Latino □ Not Hispanic/Latino □ Unknown

Race
(check all that apply)

□ US □ Other/US dependency

Sex Assigned at Birth
Country of
□ Male □ Female □ Unknown Birth

□ 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 Event Type
(check all that apply to address below)
Address Type

□ Residence at HIV
diagnosis

□ Residence at stage □ Residence at
3 (AIDS) diagnosis

perinatal exposure

□ Residence at

□ Check if SAME as

pediatric seroreverter

current address

□ Residential □ Bad address □ Correctional facility □ Foster home □ Homeless □ Military □ Other □ Postal □ Shelter □ Temporary

*Street Address
City

County

State/Country

*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.
This report to 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. MM/YYYY

(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 □ Stage 3 (AIDS) □ Perinatal exposure □ Check if SAME as facility providing information

Facility Name

*Phone (

)

*Street Address
City
Facility Type

County
Inpatient: □ Hospital
□ Other, specify

State/Country
Outpatient: □ Private physician’s office

□ Pediatric clinic

□ Pediatric HIV clinic □ Other, specify

*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+ during pregnancy □ Known HIV+ sometime before birth □ Known HIV+ at delivery
□ HIV+, time of diagnosis unknown □ HIV status unknown

Child’s biological mother’s HIV infection status (select one):

□
□

Known HIV+ before pregnancy
Known HIV+ after child’s birth

Was the biological mother counseled about HIV testing during this pregnancy,
Date of mother’s first positive test to confirm infection
/
/
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 nonprescription drugs

□ Yes □ No □ Unknown

Biological mother had HETEROSEXUAL relations with any of the following:
HETEROSEXUAL contact with intravenous/injection drug user

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

HETEROSEXUAL contact with bisexual male
HETEROSEXUAL contact with person with hemophilia/coagulation disorder with documented HIV infection
HETEROSEXUAL contact with transfusion recipient with documented HIV infection
HETEROSEXUAL contact with transplant recipient with documented HIV infection
HETEROSEXUAL contact with person with documented HIV infection, risk not specified
Biological mother had:
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

□ No
□ No
□ No
□ No
□ No
□ No

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

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

Before the diagnosis of HIV infection, this child had:

Injected nonprescription drugs

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

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)
First date received
/
/
Last date received
/
/
Received transplant of tissue/organs

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

Sexual contact with male
Sexual contact with female
Other documented risk (please include detail in Comments)

□ No
□ No
□ No
□ No

□ Unknown
□ Unknown
□ Unknown
□ Unknown

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

Dx Date

Bacterial infection, multiple or recurrent
(including Salmonella septicemia)
Candidiasis, bronchi, trachea, or lungs

Diagnosis

Dx Date

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

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

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

Diagnosis
Mycobacterium avium complex or M.
kansasii, disseminated or extrapulmonary
M. tuberculosis, pulmonary1
M. tuberculosis, disseminated
or extrapulmonary1
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

1

If a diagnosis date is entered for either tuberculosis diagnosis above, provide RVCT Case Number:

CDC 50.42B

Rev. MM/YYYY

(Page 2 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

Dx Date

Laboratory Data (record additional tests and tests not specified below in Comments) (record all dates as mm/dd/yyyy)
HIV Immunoassays (Nondifferentiating)
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 _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result □ Positive □ Negative □ Indeterminate
Collection Date
/
/
□ Point-of-care rapid test
TEST 2 □ 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 _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result □ Positive □ Negative □ Indeterminate
Collection Date
/
/
□ Point-of-care rapid test
HIV Immunoassays (Differentiating)
□ HIV-1/2 type-differentiating immunoassay
Role of test in diagnostic algorithm
(differentiates between HIV-1 Ab and HIV-2 Ab)
□ Screening/initial test □ Confirmatory/supplemental test
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result1 Overall interpretation: □ HIV-1 positive □ HIV-2 positive □ HIV positive, untypable □ HIV-2 positive with HIV-1 cross-reactivity
□ HIV-1 indeterminate □ HIV-2 indeterminate □ HIV indeterminate □ HIV negative
Analyte results: HIV-1 Ab: □ Positive □ Negative □ Indeterminate Collection Date
/
/
□ Point-of-care rapid test
HIV-2 Ab: □ Positive □ Negative □ Indeterminate 1Always complete the overall interpretation. Complete the analyte results when available.
□ HIV-1/2 Ag/Ab differentiating immunoassay (differentiates between HIV Ag and HIV Ab)
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result □ Ag positive □ Ab positive □ Both (Ag and Ab positive) □ Negative □ Invalid
Collection Date
/
/
□ Point-of-care rapid test
□ HIV-1/2 Ag/Ab and type-differentiating immunoassay (differentiates among HIV-1 Ag, HIV-1 Ab, and HIV-2 Ab)
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result2 Overall interpretation: □ Reactive □ Nonreactive □ Index value ______________
Analyte results: HIV-1 Ag: □ Reactive □ Nonreactive □ Not reportable due to high Ab level Index value
HIV-1 Ab: □ Reactive □ Nonreactive □ Reactive undifferentiated Index value
HIV-2 Ab: □ Reactive □ Nonreactive □ Reactive undifferentiated Index value
Collection Date
/
/
□ Point-of-care rapid test 2Complete the overall interpretation and the analyte results.
HIV Detection Tests (Qualitative)
TEST □ HIV-1 RNA/DNA NAAT (Qualitative) □ HIV-1 culture □ HIV-2 RNA/DNA NAAT (Qualitative) □ HIV-2 culture
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result □ Positive □ Negative □ Indeterminate
Collection Date
/
/
HIV Detection Tests (Quantitative viral load) Note: Include earliest test at or after diagnosis.
TEST 1 □ HIV-1 RNA/DNA NAAT (Quantitative viral load) □ HIV-2 RNA/DNA NAAT (Quantitative viral load)
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result □ Detectable □ Undetectable Copies/mL _____________________________ Log _____________ Collection Date
/
/
TEST 2 □ HIV-1 RNA/DNA NAAT (Quantitative viral load) □ HIV-2 RNA/DNA NAAT (Quantitative viral load)
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result □ Detectable □ Undetectable Copies/mL _____________________________ Log _____________ Collection Date
/
/
Drug Resistance Tests (Genotypic)
TEST □ HIV-1 Genotype (Unspecified)
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Collection Date
/
/
Immunologic Tests (CD4 count and percentage)
CD4 at or closest to diagnosis: CD4 count
cells/µL CD4 percentage
%
Collection Date
/
/
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
First CD4 result <200 cells/µL or <14%: CD4 count
cells/µL CD4 percentage
% Collection Date
/
/
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Other CD4 result: CD4 count
cells/µL CD4 percentage
%
Collection Date
/
/
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
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 were positive for HIV-1: Western blot, IFA, culture, viral load, qualitative NAAT (RNA or DNA), HIV-1/2 typedifferentiating immunoassay (supplemental test), stand-alone p24 antigen, or nucleotide sequence.
If laboratory tests were not documented,
is patient confirmed by a physician as
CDC 50.42B

HIV-infected
Not HIV-infected

Rev. MM/YYYY

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

(Page 3 of 4)

Date of diagnosis
Date of diagnosis

/
/

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

/
/

Birth History (for Perinatal Cases only)

□ Yes □ No □ Unknown
□ Check if SAME as current address
Address Type □ Residential □ Bad address □ Correctional facility □ Foster home □ Homeless □ Military □ Other □ Postal □ Shelter □ Temporary
Birth history available?

Residence at Birth
*Street Address

City

County

State/Country

*ZIP Code

□ Check if SAME as facility providing information

Facility of Birth

Facility Name of Birth
(if child was born at home, enter “home birth”)
Facility Type
Inpatient: □ Hospital

*Phone
(
)
Other Facility: □ Emergency room □ Corrections □ Unknown
□ Other, specify

Outpatient:

□ Other, specify

□ Other, specify

*Street Address

City

County

State/Country

*ZIP Code

Birth History

Birth Weight
lbs
oz
grams
Type □ 1-Single □ 2-Twin □ 3-More than two □ 9-Unknown
□ 1-Vaginal □ 2-Elective Cesarean □ 3-Nonelective Cesarean □ 4-Cesarean, unknown type □ 9-Unknown
Birth Defects □ Yes □ No □ Unknown
If yes, specify types
Neonatal Status □ 1-Full-term □ 2-Premature □ 9-Unknown Neonatal Gestational Age in Weeks
(99 = Unknown, 00 = None)
Delivery

Prenatal Care—Month of Pregnancy Prenatal Care Began
Prenatal Care—Total Number of Prenatal Care Visits
(99 = Unknown, 00 = None)
(99 = Unknown, 00 = None)
Did mother receive any antiretrovirals (ARVs) prior to this pregnancy?
If yes, specify all ARVs
□ Yes □ No □ Refused □ Unknown
Date began __ __ / __ __ / __ __ __ __ Date of last use __ __ / __ __ / __ __ __ __
Did mother receive any ARVs during pregnancy?
If yes, specify all ARVs
□ Yes □ No □ Refused □ Unknown
Date began __ __ / __ __ / __ __ __ __ Date of last use __ __ / __ __ / __ __ __ __
Did mother receive any ARVs during labor/delivery?
If yes, specify all ARVs
□ Yes □ No □ Refused □ Unknown
Date began __ __ / __ __ / __ __ __ __ Date of last use __ __ / __ __ / __ __ __ __

Maternal Information

Maternal DOB __ __ / __ __ / __ __ __ __

Maternal State ID Number

Maternal Last Name Soundex

Maternal Country of Birth

*Other Maternal ID (specify type of ID and ID number)

Treatment/Services Referrals (record all dates as mm/dd/yyyy)
This child ever taken any ARVs?

□ 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

/

/

□ Other (specify reason) __________________________________________________________________________________________________________
ARV medications ________________________________
Has this child ever taken PCP prophylaxis

Date began

/

/

Date of last use

/

/

□ Yes □ No □ Unknown Date began

/

/

Date of last use

/

/

□ Yes □ No □ Unknown
This child’s primary caretaker is □ 1-Biological parent □ 2-Other relative □ 3-Foster/Adoptive parent, relative □ 4-Foster/Adoptive parent, unrelated
□ 7-Social service agency □ 8-Other (please specify in comments) □ 9-Unknown
Was this child breastfed?

Comments

*Local/Optional Fields

CDC 50.42B

Rev. MM/YYYY

(Page 4 of 4)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—