Form 0920-0573 HIV Incidence Surveillance (HIS)

National HIV Surveillance System (NHSS)

Attachment 3a.
Adult HIV Confidential Case Report Form

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

*Middle Name

Alternate Name Type (ex: Alias, Married)

*Last Name

*First Name

*Middle Name

*Last Name

*Current Address, Street

Address Type □ Residential

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

*Phone
City
(
)
*Medical Record Number

Last Name Soundex

Address Date
/

County

State/Country

*ZIP Code

*Other ID Type

*Number

Adult HIV Confidential Case Report Form

U.S. Department of Health
and Human Services

(Patients >13 years of age 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
/
/

/

Centers for Disease Control
and Prevention (CDC)

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

eHARS Document UID

State Number
City/County Number

Reporting Health Dept—City/County
Document Source

Surveillance Method
□ Passive □ Follow up □ Reabstraction
Report Medium
□ 1-Field visit □ 2-Mailed □ 3-Faxed □ 4-Phone

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

□ Unknown

□ 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

State/Country

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

Inpatient:

Screening, Diagnostic, Referral Agency:

Outpatient:

□ Hospital
□ Other, specify

Date Form Completed

*ZIP Code

□ 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

Country of Birth

□ Male □ Female □ Unknown

□ US □ Other/US dependency (please specify)

Date of Birth
Vital Status

/

Alias Date of Birth

/

/

/

□ 1-Alive □ 2-Dead
Date of Death
/
/
State of Death
□ Male □ Female □ Transgender male-to-female (MTF) □ Transgender female-to-male (FTM) □ Unknown
□ Additional gender identity (specify)
Expanded Ethnicity
□ Hispanic/Latino □ Not Hispanic/Latino □ Unknown

Current Gender Identity
Ethnicity

Race
(check all that apply)

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

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 3 (AIDS) diagnosis □ Check if SAME as 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.
CDC 50.42A

Rev. MM/YYYY

(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)

□ HIV

Diagnosis Type (check all that apply to facility below)

□ Stage 3 (AIDS)

□ Check if SAME as facility providing information

Facility Name

*Phone (

)

*Street Address
County

City
Facility Type

Inpatient: □ Hospital
□ Other, specify

State/Country

Outpatient: □ Private physician’s office
□ Adult HIV clinic
□ Other, specify

*Provider Name

*Provider Phone (

*ZIP Code

Screening, Diagnostic, Referral Agency:
□ CTS □ STD clinic
□ Other, specify

Other Facility: □ Emergency room
□ Laboratory □ Corrections □ Unknown
□ Other, specify

Specialty

)

□ Pediatric Risk (please enter in Comments)

Patient History (respond to all questions) (record all dates as mm/dd/yyyy)
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
Sex with male
Sex with female
Injected nonprescription drugs
Received clotting factor for hemophilia/coagulation disorder
Specify clotting factor:

Date received

/

□ Yes
□ Yes
□ Yes
□ Yes

□ No
□ No
□ No
□ No

□ Unknown
□ Unknown
□ Unknown
□ Unknown

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

□ No
□ No
□ No
□ No
□ No
□ No
□ No

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

□ Yes
□ Yes

□ No
□ No

□ Unknown
□ Unknown

□ Yes

□ No

□ Unknown

/

HETEROSEXUAL relations with any of the following:
HETEROSEXUAL contact with intravenous/injection drug user
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
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
Worked in a healthcare or clinical laboratory setting
If occupational exposure is being investigated or considered
as primary mode of exposure, specify occupation and setting:
Other documented risk (please include detail in Comments)

Clinical: Acute HIV Infection and Opportunistic Illnesses (record all dates as mm/dd/yyyy)
Suspect acute HIV infection? If YES, complete the two items below; enter documented negative HIV test data in Laboratory Data section, and
enter patient or provider report of previous negative HIV test in HIV Testing History section.

Clinical signs/symptoms consistent with acute retroviral syndrome (e.g., fever, malaise/fatigue, myalgia, pharyngitis, rash,
lymphadenopathy)? Date of sign/symptom onset
/
/
Other evidence suggestive of acute HIV infection? If YES, please describe:
Date of evidence
/
/
Opportunistic Illnesses
Diagnosis

Dx Date

Diagnosis

Dx Date

□ Yes

□ No

□ Unknown

□ Yes

□ No

□ Unknown

□ Yes

□ No

□ Unknown

Diagnosis

Candidiasis, bronchi, trachea, or lungs

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

M. tuberculosis, pulmonary1

Candidiasis, esophageal

Histoplasmosis, disseminated or
extrapulmonary

M. tuberculosis, disseminated or
extrapulmonary1

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

1

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

CDC 50.42A

Rev. MM/YYYY

(Page 2 of 4)

—ADULT 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 HIV laboratory tests were not documented, is HIV diagnosis documented by a physician?
□ Yes □ No □ Unknown
If YES, provide date of diagnosis
/
/
Date of last documented negative HIV test (before HIV diagnosis date)
Specify type of test:
CDC 50.42A

Rev. MM/YYYY

(Page 3 of 4)

/

/
—ADULT HIV CONFIDENTIAL CASE REPORT—

Treatment/Services Referrals (record all dates as mm/dd/yyyy)
Has this patient been informed of his/her HIV infection?
□ Yes □ No □ Unknown

This patient’s partners will be notified about their HIV exposure and counseled by
□ 1-Health dept □ 2-Physician/Provider □ 3-Patient □ 9-Unknown

Evidence of receipt of HIV medical care other than laboratory test result (select one; record additional evidence in Comments)
□ 1-Yes, documented □ 2-Yes, client self-report, only Date of medical visit or prescription
/
/

For Female Patient
This patient is receiving or has been referred for gynecological or Is this patient currently pregnant?
obstetrical services □ Yes □ No □ Unknown
□ 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 Date of Birth
/
/

Child’s Last Name Soundex

Child’s State Number

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

*Phone
(
)

□ Emergency room
□ Corrections □ Unknown
□ Other, specify

Outpatient:

□ Hospital
□ Other, specify

Other Facility:

□ Other, specify

*Street Address

*ZIP Code

City

County

State/Country

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

☐ Yes ☐ No ☐ Unknown

□ Other

Date patient reported information
/
/

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 (specify reason)
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 □ Provider report
Ever had previous positive HIV test? □ Yes
Ever had a negative HIV test? □ Yes

□ No

□ No

□ NHM&E

□ Unknown

□ Unknown

Date patient reported information
/
/

□ 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 the 24 months before the first positive test

/
/

/

□ Unknown

Comments

*Local/Optional Fields

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 50.42A

Rev. MM/YYYY

(Page 4 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—