Form Cdc 50.42a - Adult Hiv Confidential Case Report Form

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Patient Identification
*Patient Name
*First Name
*Middle Name
*Last Name
Last Name Soundex
*Alternate Name Type
*First Name
*Middle Name
*Last Name
(ex: Alias, Married)
*Current Street Address
Address Type
Residential
Bad Address
Correctional Facility
*Phone (
) _______________
Foster Home
Homeless
Postal
Shelter
Temporary
City
County
State/Country
*ZIP Code
*Medical Record Number
*Other ID Type:
Number:
Adult HIV Confidential Case Report Form
U.S. Department of Health
Centers for Disease Control
& Human Services
and Prevention
(Patients >13 Years of Age at Time of Diagnosis)
* Information NOT transmitted to CDC
Form approved OMB no. 0920-0573 Exp. 02/29/2016
Health Department Use Only
Date Received at Health Department
eHARS Document UID __________________
State Number ___________________
__ __ /__ __ /__ __ __ __
Reporting Health Dept - City/County
City/County Number
Document Source _________________________
Surveillance Method
Active
Passive
Follow up
Reabstraction
Unknown
Did this report initiate a new case investigation?
Report Medium
1-Field Visit
2-Mailed
3-Faxed
4-Phone
Yes
No
Unknown
5-Electronic Transfer
6-CD/Disk
Facility Providing Information (record all dates as mm/dd/yyyy)
Facility Name
*Phone (
) ______________________
*Street Address
City
County
State/Country
ZIP Code
Facility
Screening, Diagnostic, Referral
Inpatient:
Outpatient:
Other Facility
Hospital
Private Physician’s Office
:
Emergency Room
Type
Agency
:
CTS
STD Clinic
Other, specify ________________
Adult HIV Clinic
Laboratory
Corrections
Unknown
Other, specify _____________
Other, specify ______ __________
Other, specify _________________
*Person Completing Form
*Phone (
) ______________________
Date Form Completed
__ __ /__ __ /__ __ __ __
Patient Demographics (record all dates as mm/dd/yyyy)
Sex assigned at Birth
Male
Female
Unknown
Country of Birth
US
Other/US Dependency (please specify) ______________________
Date of Birth
Alias Date of Birth
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
Date of Death
State of Death ____________________________
Vital Status
1-Alive
2-Dead
__ __ /__ __ /__ __ __ __
Male
Female
Transgender Male-to-Female (MTF)
Transgender Female-to-Male (FTM)
Unknown
Current Gender Identity
Additional gender identity (specify) _____________________________________
___________________
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Unknown
*Expanded Ethnicity
Race
American Indian/Alaska Native
Asian
Black/African American
________________________
*Expanded Race
(check all that apply)
Native Hawaiian/Other Pacific Islander
White
Unknown
Residence at Diagnosis (add additional addresses in Comments)
Address Type
(Check all that apply to address below)
Residence at HIV diagnosis
Residence at AIDS diagnosis
Check if SAME as Current Address
*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. 3/2013
(Page 1 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—

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