Form Cdc 50.42b - Pediatric 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
Perinatal Exposure (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
Inpatient:
Outpatient:
Other Facility
Hospital
Private Physician’s Office
Pediatric Clinic
:
Emergency Room
Laboratory
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Type
Other, specify _____________
Pediatric HIV Clinic
Other, specify _____________
Unknown
Other, specify _________________
*Provider Name
*Specialty
*Provider Phone (
) ______________________
Patient History (respond to all questions) (record all dates as mm/dd/yyyy)
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Child’s biological mother’s HIV infection status (select one):
1-Refused HIV testing
2-Known to be uninfected after this child’s birth
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3-Known HIV+ before pregnancy
4-Known HIV+ during pregnancy
5-Known HIV+ sometime before birth
6-Known HIV+ at delivery
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7-Known HIV+ after child’s birth
8-HIV+, time of diagnosis unknown
9-HIV status unknown
Date of mother’s first positive HIV
Was the biological mother counseled about HIV testing during this pregnancy,
__ __ /__ __ /__ __ __ __
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confirmatory test:
labor, or delivery?
Yes
No
Unknown
After 1977 and before the earliest known diagnosis of HIV infection, this child’s biological mother had:
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Perinatally acquired HIV infection
Yes
No
Unknown
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Injected non-prescription drugs
Yes
No
Unknown
Biological Mother had 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
Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments section)
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Yes
No
Unknown
First date received
Last date received
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
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Received transplant of tissue/organs or artificial insemination
Yes
No
Unknown
this child had:
Before the diagnosis of HIV infection,
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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:
___ ___ / ___ ___ / ___ ___ ___ ___
Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments section)
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Yes
No
Unknown
First date received
Last date received
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Received transplant of tissue/organs
Yes
No
Unknown
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Sexual contact with male
Yes
No
Unknown
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Sexual contact with female
Yes
No
Unknown
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Other Documented Risk (please include detail in Comments section)
Yes
No
Unknown
CDC 50.42B
Rev. 3/2013
(Page 2 of 4)
—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—
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