Form Cdc 50.42b - Pediatric Hiv Confidential Case Report Form Page 4
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4Birth History (for Perinatal Cases only)
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Birth History Available
Yes
No
Unknown
Check if SAME as Current Address
Residence at Birth
* Street Address
City
County
State/Country
*ZIP Code
Hospital of Birth
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Check if SAME as Facility Providing Information
Facility Name
ZIP Code
*Phone (
) _____________
*Street Address
City
County
State/Country
Birth History
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Birth Weight
Type
1-Single
2-Twin
Delivery
1-Vaginal
2-Elective Cesarean
3-Non-Elective Cesarean
______ lbs _______ oz ______ grams
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3->2
9-Unknown
4-Cesarean, unknown type
9-Unknown
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Birth Defects
If yes, please specify:
Yes
No
Unknown
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Neonatal Status
Neonatal Gestational Age in Weeks:
___________ (99–Unknown)
1-Full-term
2-Premature
Unknown
Gestational Month
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Prenatal Care – Total number of
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Prenatal Care Began
(00-None, 99-Unknown)
prenatal care visits:
(00-None, 99-Unknown)
If yes, please specify all:
Did mother receive any Anti-retrovirals (ARVs) prior to this pregnancy:
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Yes
No
Refused
Unknown
If yes, please specify all:
Did mother receive any ARVs during pregnancy?
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Yes
No
Unknown
If yes, please specify all:
Did mother receive any ARVs during labor/delivery?
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Yes
No
Unknown
Maternal Information
Maternal DOB
Maternal Soundex
Maternal Stateno
Maternal Country of Birth
Number:
*Other Maternal ID-Mother's Name:
Services Referrals (record all dates as mm/dd/yyyy)
This child received or is receiving:
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Neonatal ARVs for HIV prevention:
Date:
Yes
No
Unknown
___ ___ / ___ ___ / ___ ___ ___ ___
If Yes, please specify: 1)
2)
3)
4)
5)
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Date:
Anti-retroviral therapy for HIV treatment:
Yes
No
Unknown
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PCP Prophylaxis:
Yes
No
Unknown Date:
Was this child breastfed?
Yes
No
Unknown
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This child’s primary
1- Biological Parent
2- Other Relative
3- Foster/Adoptive parent, relative
4- Foster/Adoptive parent, unrelated
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caretaker is:
7- Social Service Agency
8- Other (please specify in comments)
9- Unknown
*Comments
*Local / Optional Fields
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 50.42B
Rev. 3/2013
(Page 4 of 4)
—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—
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