Form Cdc 50.42b - Pediatric 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 Birth, Call Me)
Address Type
Residential
Bad Address
Correctional Facility
*Current Street Address
*Phone (
) _______________
Foster Home
Homeless
Postal
Shelter
Temporary
City
County
State/Country
*ZIP Code
*Medical Record Number
*Other ID Type:
Number:
Pediatric 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
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
Inpatient:
Outpatient:
Other Facility
Hospital
Private Physician’s Office
Pediatric Clinic
:
Emergency Room
Laboratory
Type
Other, specify _____________
Pediatric HIV Clinic
Other, specify ____________ ____ ___
Unknown
Other, specify _________________
*Person Completing Form
*Phone (
) ______________________
Date Form Completed __ __ /__ __ /__ __ __ __
Patient Demographics (record all dates as mm/dd/yyyy)
Sex assigned at Birth
Country of
Diagnostic Status at Report
3-Perinatal HIV Exposure
US
Other/ US Dependency
Male
Female
Unknown
Birth
4-Pediatric HIV
5-Pediatric AIDS
6-Pediatric Seroreverter
(please specify) _____________
Date of Birth __ __ /__ __ /__ __ __ __
Alias Date of Birth __ __ /__ __ /__ __ __ __
______________________
Date of Death __ __ /__ __ /__ __ __ __
State of Death
Vital Status
1-Alive
2-Dead
Date of Last Medical Evaluation __ __ /__ __ /__ __ __ __
Date of Initial Evaluation for HIV __ __ /__ __ /__ __ __ __
________________
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Unknown
*ExpandedEthnicity
Race
American Indian/Alaska Native
Asian
Black/African American
__________________
*Expanded Race
(check all that apply)
Native Hawaiian/Pacific Islander
White
Unknown
Residence at Diagnosis (add additional addresses in Comments)
Address Type
Residence at
Residence at
Residence at
Residence at Pediatric
Check if SAME as
(Check all that apply to address below)
HIV diagnosis
AIDS diagnosis
Perinatal Exposure
Seroreverter
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 50.42B
Rev. 3/2013
(Page 1 of 4)
—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

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