Michigan Adult Hiv Confidential Case Report Form
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2Michigan Adult HIV Confidential Case Report Form
STICKY #:26-
Surveillance Date Entered:
(Patients > 13 years of age at time of diagnosis)
I. SURVEILLANCE USE ONLY
DCH FORM #1355 Modified February 2016
Document ID
Soundex Code
Date Received at Surveillance
State Number
MI00-
________/________/________
Document Source
Report Status
Report Medium
Surveillance Method
New
Update
A
F
P
R
II. PATIENT IDENTIFIER INFORMATION
Patient Legal Name Last:____________________________ First:_________________________ Middle:______________
Alias
Maiden Last:____________________________ First:_________________________ Middle:______________
Address Type:
Residential
Correctional
P.O.
Temporary
Homeless
Shelter
Foster Home
Current Address:__________________________________ City:_______________________ County:__________________
State:_______ Zip:___________ Phone:_________________ Mobile:____________________ SS#:____________________
Residence at Diagnosis
Residence at HIV diagnosis
Residence at Stage 3 (AIDS) diagnosis
(check all that apply):
Same as Current Address
Address:____________________________________________________________________
City:___________________________ County:_____________________ State/Country:_______________ Zip:__________
III. FACILITY OF DIAGNOSIS
Site of 1st Positive test for HIV Diagnosis
Site of Stage 3 (AIDS) Diagnosis
Facility Name:______________________________________________________________ Phone:_____________________
Address:____________________________________ City:_______________________ State:________ Zip:_____________
Provider Name Last:____________________ First:__________________ Provider Specialty:________________________
Facility Type:
Private Provider
Hosp Inpt
Hosp Out
ED
ID Clinic
LHD
CBO
CTR
Other
VI. CURRENT PROVIDER OF HIV CARE (
Same as Facility of Diagnosis)
Provider Name Last:____________________ First:___________________ Facility:________________________________
City:_______________________ State:______ Zip:________ Phone:______________ Med Rec No:___________________
V. FACILITY PROVIDING INFORMATION (
Same as Facility of Diagnosis) (
Same as Current Provider of Care)
Date Form Completed:________/_______/_________ Person Completing Form:___________________________________
Facility Completing Form:__________________________________________________ Phone:________________________
VI. DEMOGRAPHIC INFORMATION – COMPLETE ALL FIELDS
Case Status:
HIV Infection
Stage 3 (AIDS)
Do you suspect this is an acute (recent) infection?
Y
N
Sex at Birth
Gender Identity
Date of Birth
Country of Birth
Vital Status
Death Date
Marital Status
Male
Male
___/___/____
US
Unk
Alive
____/____/____
Single
Female
Female
Dead
Married
Trans
Female
Other (specify):
Unk
Divorced
to
Alias DOB
State/Terr of
Trans
Male
_____________
Widowed
to
___/___/____
Death:_________
Lives w/ Ptnr
Race:
Black (African American)
White
Asian
American Indian/Alaskan
Native Hawaiian/PI
Ethnicity:
Arab
Y
N
Unk
Latino/Hispanic
Y
N
Unk
VII. PATIENT HISTORY – COMPLETE ALL FIELDS
Before HIV Diagnosis, patient had:
Y
N
Unk
Before HIV Diagnosis, patient had:
Y
N
Unk
HETEROSEXUAL SEX WITH:
Sex with a male
- An injection drug user (IDU)
Sex with a female
- A bisexual male (females only)
Injected non-prescription drugs
- Person known to have HIV/AIDS
Transplant/transfusion/clotting disorder*
*and is claiming this as their source of HIV infection
High risk sex (detail in comment section)
Was patient perinatally infected?
VIII. TREATMENT/SERVICES REFERRALS (MI law requires providers to notify known partners or request help from LHD)
Patient Informed of HIV infection?
Y
N
Unk
Patient’s partners will be notified of exposure and counseled by:
Local Health Department
Clinical Care Provider
IX. WOMEN ONLY
Patient currently pregnant?
Y
N
Unk
IF YES, referred to OB?
Y
N
Unk
EDC (Due Date):____/____/____
Patient delivered live infants?
Y
N
Unk
IF YES, Most Recent Delivery Date:_____/______/_______
Delivery Hospital:__________________________ City:_________________ State:____ Child Name:___________________
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