Form Cdc 50.42a - Adult Hiv Confidential Case Report Form Page 2
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4STATE/LOCAL USE ONLY
– Patient identifier information is not transmitted to CDC! –
Physician’s Name: (Last, First, M.I.)
Medical Record
______________________________________________________
No.______________
Phone No: (
) __________________
Hospital/Facility:
Person Completing Form:
___________________________________
___________________________________
Facility of Diagnosis (add additional facilities in Comments)
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Diagnosis Type
HIV
AIDS
(check all that apply to facility below)
Check if SAME as Facility Providing Information
Facility Name
*Phone (
) _______________________
*Street Address
City
County
State/Country
ZIP Code
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Facility
Screening, Diagnostic, Referral Agency
:
Other Facility
:
Emergency Room
Inpatient:
Outpatient:
Hospital
Private Physician’s Office
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Type
CTS
STD Clinic
Laboratory
Corrections
Unknown
Other, specify
Adult HIV Clinic
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Other, specify ________________
___________
Other, specify _________________
Other, specify ______ __________
*Provider Name
*Specialty
*Provider Phone (
) _______________________
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Patient History
Pediatric risk
(respond to all questions) (record all dates as mm/dd/yyyy)
(please enter in Comments)
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
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Sex with male
Yes
No
Unknown
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Sex with female
Yes
No
Unknown
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Injected non-prescription drugs
Yes
No
Unknown
Received clotting factor for hemophilia/
Specify clotting factor:
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Yes
No
Unknown
coagulation disorder
Date received (mm/dd/yyyy):
__ __ /__ __ /__ __ __ __
HETEROSEXUAL relations with any of the following:
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HETEROSEXUAL contact with intravenous/injection drug user
Yes
No
Unknown
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HETEROSEXUAL contact with bisexual male
Yes
No
Unknown
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HETEROSEXUAL contact with person with hemophilia/coagulation disorder with documented HIV infection
Yes
No
Unknown
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HETEROSEXUAL contact with transfusion recipient with documented HIV infection
Yes
No
Unknown
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HETEROSEXUAL contact with transplant recipient with documented HIV infection
Yes
No
Unknown
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HETEROSEXUAL contact with person with documented HIV infection, risk not specified
Yes
No
Unknown
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Yes
No
Unknown
Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments section)
First date received __ __ /__ __ /__ __ __ __ Last date received __ __ /__ __ /__ __ __ __
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Received transplant of tissue/organs or artificial insemination
Yes
No
Unknown
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Yes
No
Unknown
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:
_________________________________________________________________________________________________
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Other documented risk (please include detail in Comments section)
Yes
No
Unknown
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 50.42A
Rev. 3/2013
(Page 2 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—
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