Pediatric Hiv Exposure Reporting (Pher) - U.s. Department Of Health & Human Services

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Pediatric HIV Exposure Reporting (PHER)
U.S. Department of Health
Centers for Disease Control
& Human Services
and Prevention
Form Approved OMB No. 0920-0573 Exp. Date 02/29/2016
1. If information on the mother is not available, was the child adopted, or in foster care?
Yes
No
Not applicable
2. Records abstracted
(1 = Abstracted, 2 = Attempted—record not available, 3 = Not abstracted, 4 = Attempted—will try again)
_____Prenatal care records
_____ Pediatric medical records (non-HIV clinic or provider)
_____Maternal HIV clinic records
_____ Birth certificate
_____Labor and delivery records
_____ Death certificate
_____Pediatric birth records
_____ Health department records
_____Pediatric HIV medical records
_____ Other (Specify.) ________________________________________________
3. Weeks’ gestation at first prenatal care visit
__ __ weeks
4. Was the mother screened for any of the following during pregnancy?
(Check test performed before birth, but closest to date of delivery or admission to labor and delivery.)
Yes
Date (mm/dd/yyyy)
No
Not documented
Record not available
Unknown
__ __/__ __/__ __ __ __
Group B strep
__ __/__ __/__ __ __ __
Hepatitis B (HBsAg)
__ __/__ __/__ __ __ __
Rubella
__ __/__ __/__ __ __ __
Syphilis
5. Diagnosis (for the mother) of the following conditions during this pregnancy or at the time of labor and delivery
(See instructions for data abstraction for definitions.)
Yes
Date (mm/dd/yyyy)
No
Not documented
Record not available
Unknown
__ __/__ __/__ __ __ __
Bacterial vaginosis
__ __/__ __/__ __ __ __
Chlamydia trachomatis infection
__ __/__ __/__ __ __ __
Genital herpes
__ __/__ __/__ __ __ __
Gonorrhea
__ __/__ __/__ __ __ __
Group B strep
__ __/__ __/__ __ __ __
Hepatitis B (HbsAg+)
__ __/__ __/__ __ __ __
Hepatitis C
__ __/__ __/__ __ __ __
PID
__ __/__ __/__ __ __ __
Syphilis
__ __/__ __/__ __ __ __
Trichomoniasis
6. Mother’s reproductive history
_________ No. of previous pregnancies
__________ No. of previous miscarriages or stillbirths
_________ No. of previous live births
__________ No. of previous induced abortions OR __________ Total No. of previous abortions
7. Complete the chart for all siblings.
Date of birth
Age
HIV serostatus
State No.
City No.
(mm/dd/yyyy)
(yrs: mos as of mm/yyyy)
(See list.)
Sib 1
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
______________
Sib 2
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
______________
Sib 3
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
______________
Sib 4
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
_______________
HIV serostatus: 1 = Infected, 2 = Not infected, 3 = Indeterminate, 9 = Not documented, U = Unknown
Public reporting burden of this collection of information is estimated to average 18 to 30 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 completed form to this address.
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).

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