Pediatric HIV Confidential Case Report Form

National HIV Surveillance System (NHSS)

Attachment 3(b)
Pediatric HIV Confidential Case Report Form

I. Patient Identification (record all dates as mm/dd/yyyy)
*First Name

*Middle Name

Alternate Name Type (example: Birth, Call Me)

*Last Name

*First Name

*Middle Name

□ Bad address □ Correctional facility
□ Foster home □ Homeless □ Military □ Other
□ Postal □ Shelter □ Temporary
City

*Last Name

*Current Address, Street

Address Type □ Residential

*Phone
(
)
*Medical Record Number

Last Name Soundex

Address Date
/

County

State/Country

*ZIP Code

*Other ID Type

*Number

Pediatric HIV Confidential Case Report Form

U.S. Department of Health
and Human Services

Centers for Disease Control
and Prevention (CDC)

(Patients aged <13 years at time of perinatal exposure or patients aged <13 years at time of
diagnosis) *Information NOT transmitted to CDC

II. Health Department Use Only (record all dates as mm/dd/yyyy)
Date Received at Health Department
/
/
Reporting Health Dept—City/County

eHARS Document UID

Document Source

Surveillance Method

Did this report initiate a new case investigation?
□ Yes □ No □ Unknown

Report Medium
□ 1-Field visit □ 2-Mailed

/

Form approved OMB no. NNNN-NNNN Exp. MM/DD/YYYY

State Number

City/County Number

□ Active

□ Passive

□ 3-Faxed

□ Follow up
□ 4-Phone

□ Reabstraction

□ Unknown

□ 5-Electronic transfer

□ 6-CD/disk

III. Facility Providing Information (record all dates as mm/dd/yyyy)
Facility Name

*Phone
(
)

*Street Address
City
Facility
Type

County

□ Hospital

Inpatient:

State/Country

*ZIP Code

□ Private physician’s office □ Pediatric clinic
□ Pediatric HIV clinic □ Other, specify
Outpatient:

□ Other, specify

Date Form Completed

□ Unknown □ Other, specify _____________________

*Person Completing Form
/

□ Emergency room □ Laboratory

Other Facility:

*Phone
(
)

/

IV. Patient Demographics (record all dates as mm/dd/yyyy)
Diagnostic Status at Report □ 3-Perinatal HIV exposure
□ 4-Pediatric HIV □ 5-Pediatric AIDS □ 6-Pediatric seroreverter
Date of Birth

/

Vital Status □ 1-Alive

Sex Assigned at Birth
Country of
□ Male □ Female □ Unknown Birth
Alias Date of Birth

/
Date of Death

□ 2-Dead

Date of Last Medical Evaluation

/

/

□ Boy □ Girl □ Transgender boy
□ Additional gender identity (specify)
□ Declined to answer □ Unknown

Date Identified

__ __ / __ __ / __ __ __ __

(specify)

/

/

State of Death

/

Date of Initial Evaluation for HIV

/

Gender Identity

□ US □ Other/US dependency

/

/

□ Transgender girl

Sexual Orientation

□ Straight or heterosexual □ Lesbian or gay □ Bisexual
□ Additional sexual orientation (specify) _____________________________________________________________________________
□ Declined to answer □ Unknown

Date Identified

__ __ / __ __ / __ __ __ __

□ Hispanic/Latino □ Not Hispanic/Latino □ Unknown
Race
□ American Indian/Alaska Native □ Asian □ Black/African American
(check all that apply) □ Native Hawaiian/Other Pacific Islander □ White □ Unknown
Ethnicity

Expanded Ethnicity
Expanded Race

V. Residence at Diagnosis (add additional addresses in Comments) (record all dates as mm/dd/yyyy)
Address Event Type
(check all that apply to address below)
Address Type

□ Residence at HIV
diagnosis

□ Residence at stage □ Residence at
3 (AIDS) diagnosis

perinatal exposure

□ Residence at

□ Check if SAME as

pediatric seroreverter

current address

□ Residential □ Bad address □ Correctional facility □ Foster home □ Homeless □ Military □ Other □ Postal □ Shelter □ Temporary

*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.
This report to 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, 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. MM/YYYY

(Page 1 of 6)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

VI. Facility of Diagnosis (add additional facilities in Comments)
Diagnosis Type (check all that apply to facility below)

□ HIV □ Stage 3 (AIDS) □ Perinatal exposure □ Check if SAME as facility providing information

Facility Name

*Phone (

)

*Street Address
City

County

Facility Type

Inpatient: □ Hospital
□ Other, specify

State/Country
Outpatient: □ Private physician’s office

□ Pediatric clinic

□ Pediatric HIV clinic □ Other, specify

*Provider Name

*Provider Phone (

*ZIP Code
Other Facility: □ Emergency room

□ Laboratory

□ Unknown □ Other, specify
Specialty

)

VII. Patient History (respond to all questions) (record all dates as mm/dd/yyyy)

□ Refused HIV testing □ Known to be uninfected after this child’s birth
□ Known HIV+ during pregnancy □ Known HIV+ sometime before birth □ Known HIV+ at delivery
□ HIV+, time of diagnosis unknown □ HIV status unknown
Date of birthing person’s first positive test result to confirm infection
Child breastfed/chestfed by birthing person □ Yes □ No □ Unknown

Birthing person’s HIV infection status (select one):

□
□

Known HIV+ before pregnancy
Known HIV+ after child’s birth

Child received premasticated/pre-chewed food from birthing person
□ Yes □ No □ Unknown
After 1977 and before the earliest known diagnosis of HIV infection, the birthing person had:
Perinatally acquired HIV infection
□ Yes □ No □ Unknown
/

/

Injected nonprescription drugs

□ Yes □ No □ Unknown

Birthing person had HETEROSEXUAL relations with any of the following:
HETEROSEXUAL contact with person who injected drugs

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

HETEROSEXUAL contact with bisexual male
HETEROSEXUAL contact with person with hemophilia/coagulation disorder with documented HIV infection
HETEROSEXUAL contact with transfusion recipient with documented HIV infection
HETEROSEXUAL contact with transplant recipient with documented HIV infection
HETEROSEXUAL contact with person with documented HIV infection, risk not specified
Birthing person had:
Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments)
First date received
/
/
Last date received
/
/
Received transplant of tissue/organs or artificial insemination

□ No
□ No
□ No
□ No
□ No
□ No

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

□ Yes □ No □ Unknown
□ Yes □ No □ Unknown

Before the diagnosis of HIV infection, this child had:

Injected nonprescription drugs

□ Yes □ No □ Unknown
□ Yes □ No □ Unknown

Received clotting factor for hemophilia/coagulation disorder
Specify clotting factor:
Date received
/
/
Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments)
First date received
/
/
Last date received
/
/
Received transplant of tissue/organs

□ Yes □ No □ Unknown
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

Sexual contact with male
Sexual contact with female
Been breastfed/chestfed by non-birthing person
Received premasticated/pre-chewed food from non-birthing person
Other documented risk (include detail in Comments)

□ No
□ No
□ No
□ No
□ No
□ No

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

VIII. Clinical: Opportunistic Illnesses (record all dates as mm/dd/yyyy)
Diagnosis

Dx Date

Bacterial infection, multiple or recurrent
(including Salmonella septicemia)
Candidiasis, bronchi, trachea, or lungs

Diagnosis

Dx Date

HIV encephalopathy

Candidiasis, esophageal

Herpes simplex: chronic ulcers (>1 mo. duration),
bronchitis, pneumonitis, or esophagitis
Histoplasmosis, disseminated or extrapulmonary

Carcinoma, invasive cervical

Isosporiasis, chronic intestinal (>1 mo. duration)

Coccidioidomycosis, disseminated
or extrapulmonary
Cryptococcosis, extrapulmonary

Kaposi’s sarcoma

Cryptosporidiosis, chronic intestinal
(>1 mo. duration)
Cytomegalovirus disease
(other than in liver, spleen, or nodes)
Cytomegalovirus retinitis (with loss
of vision)

Lymphoid interstitial pneumonia and/or
pulmonary lymphoid
Lymphoma, Burkitt’s (or equivalent)
Lymphoma, immunoblastic (or equivalent)
Lymphoma, primary in brain

Diagnosis
Mycobacterium avium complex or M.
kansasii, disseminated or extrapulmonary
M. tuberculosis, pulmonary1
M. tuberculosis, disseminated
or extrapulmonary1
Mycobacterium, of other/unidentified
species, disseminated or extrapulmonary
Pneumocystis pneumonia
Pneumonia, recurrent in 12 mo. period
Progressive multifocal
leukoencephalopathy
Toxoplasmosis of brain, onset at >1 mo.
of age
Wasting syndrome due to HIV

1

If a diagnosis date is entered for either tuberculosis diagnosis above, provide RVCT Case Number:

CDC 50.42B

Rev. MM/YYYY

(Page 2 of 6)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

Dx Date

IX. Laboratory Data (record additional tests and tests not specified below in Comments) (record all dates as mm/dd/yyyy)
HIV Immunoassays
TEST □ HIV-1 IA □ HIV-1/2 IA □ HIV-1/2 Ag/Ab □ HIV-2 IA
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name __________________________________________________
Result □ Positive □ Negative □ Indeterminate
Collection Date
/
/
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
TEST □ HIV-1/2 Ag/Ab differentiating immunoassay (differentiates between HIV Ag and HIV Ab)
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name __________________________________________________
Overall: □ Reactive □ Nonreactive
Collection Date
/
/
Analyte results: HIV-1 Ag: □ Reactive □ Nonreactive
HIV-1/2 Ab: □ Reactive □ Nonreactive
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
TEST □ HIV-1/2 Ag/Ab and type-differentiating immunoassay (differentiates among HIV-1 Ag, HIV-1 Ab, and HIV-2 Ab)
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name __________________________________________________
Result

Result3 Overall interpretation: □ Reactive □ Nonreactive □ Index Value ____________ Collection Date
/
/
Analyte results: HIV-1 Ag: □ Reactive □ Nonreactive □ Not reportable due to high Ab level Index Value
HIV-1 Ab: □ Reactive □ Nonreactive □ Reactive undifferentiated Index Value
HIV-2 Ab: □ Reactive □ Nonreactive □ Reactive undifferentiated Index Value
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
TEST □ HIV-1/2 type-differentiating immunoassay (supplemental) (differentiates between HIV-1 Ab and HIV-2 Ab)
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name __________________________________________________
Result4 Overall interpretation: □ HIV positive, untypable □ HIV-1 positive with HIV-2 cross-reactivity □ HIV-2 positive with HIV-1 cross-reactivity
□ HIV negative □ HIV indeterminate □ HIV-1 indeterminate □ HIV-2 indeterminate □ HIV-1 positive □ HIV-2 positive
Analyte results: HIV-1 Ab: □ Positive □ Negative □ Indeterminate Collection Date
/
/
HIV-2 Ab: □ Positive □ Negative □ Indeterminate
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
TEST □ HIV-1 WB □ HIV-1 IFA □ HIV-2 WB
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name __________________________________________________
Result □ Positive □ Negative □ Indeterminate
Testing Option (if applicable) □ Point-of-care test by provider
HIV Detection Tests

Collection Date

/

/

□ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample

TEST □ HIV-1/2 RNA NAAT (Qualitative)
Lab Name ______________________________________________________
Test Brand Name/Manufacturer _____________________________________Provider Name __________________________________________________
Facility Name ____________________________________________________Collection Date
/
/
Result □ HIV-1 □ HIV-2 □ Both (HIV-1 and HIV-2) □ HIV, not differentiated (HIV-1 or HIV-2) □ Neither (negative)
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
TEST □ HIV-1 RNA NAAT (Qualitative and Quantitative)
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name __________________________________________________
Result Qualitative: □ Reactive □ Nonreactive
Collection Date
/
/
Analyte results: HIV-1 Quantitative: □ Detectable above limit □ Detectable within limits □ Detectable below limit
Copies/mL
Log
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
TEST □ HIV-1 RNA/DNA NAAT (Qualitative) □ HIV-1 culture □ HIV-2 RNA/DNA NAAT (Qualitative) □ HIV-2 culture
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name __________________________________________________
Result □ Positive □ Negative □ Indeterminate
Collection Date
/
/
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
TEST □ HIV-1 RNA/DNA NAAT (Quantitative) □ HIV-2 RNA/DNA NAAT (Quantitative)
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name __________________________________________________
Result □ Detectable above limit □ Detectable within limits □ Detectable below limit □ Not detected Copies/mL
Log
Collection Date
/
/
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
Drug Resistance Tests (Genotypic)
TEST □ HIV-1 Genotype (Unspecified)
Test Brand Name/Manufacturer ____________________________________
Lab Name _______________________________________________________Facility Name ___________________________________________________
Provider Name ___________________________________________________Collection Date
Immunologic Tests (CD4 count and percentage)

/

/

CD4 count
cells/µL CD4 percentage
% Collection Date
/
/
Test Brand Name/Manufacturer _____________________________________Lab Name ______________________________________________________
Facility Name ____________________________________________________Provider Name _________________________________________________

CDC 50.42B

Rev. MM/YYYY

(Page 3 of 6)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

IX. Laboratory Data (record additional tests and tests not specified below in Comments) (record all dates as mm/dd/yyyy) (cont)
Documentation of Tests
Did documented laboratory test results meet approved HIV diagnostic algorithm criteria? □ Yes □ No □ Unknown
If YES, provide specimen collection date of earliest positive test result for this algorithm
/
/
Complete the above only if none of the following were positive for HIV-1: Western blot, IFA, culture, quantitative NAAT (RNA or DNA), qualitative NAAT (RNA or
DNA), HIV-1/2 type-differentiating immunoassay (supplemental test), stand-alone p24 antigen, or nucleotide sequence.
Is earliest evidence of diagnosis
HIV-infected
□ Yes □ No □ Unknown
Date of diagnosis by physician
/
/
Date of diagnosis by physician
/
/
documented by a physician rather Not HIV-infected □ Yes □ No □ Unknown
than by laboratory test results?
2Results

not directly observed by a provider should be recorded in HIV Testing History.
Complete the overall interpretation and the analyte results.
4
Always complete the overall interpretation. Complete the analyte results when available.
3

X. Birth History (for patients exposed perinatally with or without consequent infection)

□ Yes □ No □ Unknown
□ Check if SAME as current address
Address Type □ Residential □ Bad address □ Correctional facility □ Foster home □ Homeless □ Military □ Other □ Postal □ Shelter □ Temporary
Birth history available?

Residence at Birth
*Street Address

City

County

State/Country

*ZIP Code

□ Check if SAME as facility providing information

Facility of Birth

Facility Name of Birth
(if child was born at home, enter “home birth”)
Facility Type
Inpatient: □ Hospital

□ Other, specify

*Phone
(
)
Other Facility: □ Emergency room □ Corrections □ Unknown
□ Other, specify

Outpatient:

_______________________ □ Other, specify

*Street Address

City

County

State/Country

Birth History

Birth Weight

lbs

*ZIP Code
oz

grams Type

□ 1-Single □ 2-Twin □ 3-More than two □ 9-Unknown

Delivery □ Vaginal □ Cesarean □ Unknown
If Cesarean delivery, mark all the following indications that apply.
□ HIV indication (high viral load)
□ Previous Cesarean (repeat)
□ Malpresentation (breech, transverse)
□ Prolonged labor or failure to progress
□ Birthing person’s or physician’s preference
□ Fetal distress
□ Placenta abruptia or p. previa
□ Other (e.g., herpes, disproportion) (Specify) ___________________________________________
□ Not specified
Birth Information
Date
Time (use military time: noon = 12:00; midnight = 00:00)
Rupture of membranes
/
/
:
Delivery
/
/
:
Congenital Disorders
□ Yes □ No □ Unknown If YES, specify types
Neonatal Status

□ 1-Full-term □ 2-Premature □ 9-Unknown

Was a toxicology screen
done on the infant
after birth?

Neonatal Gestational Age in Weeks ____ (99 = Unknown, 00 = None)
Result

Not screened
Alcohol

□ Yes □ No □ Unknown

Amphetamines

(If screening for the same
substance was done on
more than one occasion,
record additional dates and
results in Comments)

Barbiturates
Benzodiazepines
Cocaine
Crack cocaine
Fentanyl
Hallucinogens
Heroin
K2
Marijuana

□
□
□
□
□
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Date of screen
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Positive

Negative

Unknown

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(cannabis, THC, cannabinoids)

□
Methamphetamines
□
Nicotine (any tobacco)
□
Opiates
□
PCP
□
Other (specify)
□
Specific drug(s) not documented □
Methadone

CDC 50.42B

Rev. MM/YYYY

(Page 4 of 6)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

XI. Birthing Person History (for patients exposed perinatally with or without consequent infection)
Birthing Person Date of Birth __ __ / __ __ / __ __ __ __

Birthing Person Last Name Soundex

Birthing Person Country of Birth

Birthing Person State ID Number

Birthing Person City/County ID Number

*Other Birthing Person ID (specify type of ID and ID number)

Prenatal Care—Month of Pregnancy Prenatal Care Began
Prenatal Care—Total Number of Prenatal Care Visits
(99 = Unknown, 00 = None)
(99 = Unknown, 00 = None)
If YES, specify how many previous pregnancies _______________
Has the birthing person ever been pregnant
Year outcome occurred
Pregnancy outcome (select one)
before this pregnancy? Include previous
Live birth
Miscarriage or Stillbirth
Induced abortion
(9999 = Unknown)
pregnancies that ended in a live birth,
i.
□
□
□
miscarriage, stillbirth, or induced abortion.
ii.
□
□
□
□ Yes □ No □ Unknown
iii.
□
□
□
iv.
□
□
□
v.
□
□
□
(Record additional pregnancy outcomes in Comments)
Was a test result (with a specimen collection date within the 6 weeks on or before delivery) documented in the birthing person’s labor/delivery record
CD4 □ Yes □ No □ Unknown
Quantitative NAAT (RNA or DNA) □ Yes □ No □ Unknown
Did birthing person receive any antiretrovirals (ARVs) prior to this pregnancy? □ Yes □ No □ Refused □ Unknown
Date began __ __ / __ __ / __ __ __ __
Date of last use __ __ / __ __ / __ __ __ __
If YES, specify all ARVs ___________________________________________________________________________________________________________
Did birthing person receive any ARVs during this pregnancy? □ Yes □ No □ Refused □ Unknown
Date began __ __ / __ __ / __ __ __ __
Date of last use __ __ / __ __ / __ __ __ __
If YES, specify all ARVs ___________________________________________________________________________________________________________
If NO, select reason □ No prenatal care □ Birthing person known to be HIV-negative during pregnancy □ Unknown
□ HIV serostatus of birthing person unknown □ Other (specify)
Did birthing person receive any ARVs during labor/delivery? □ Yes □ No □ Refused □ Unknown
Date began __ __ / __ __ / __ __ __ __
Date of last use __ __ / __ __ / __ __ __ __
If YES, specify all ARVs ___________________________________________________________________________________________________________
If NO, select reason □ Precipitous delivery/STAT Cesarean delivery □ HIV serostatus of birthing person unknown □ Birth not in hospital
□ Birthing person tested HIV negative during pregnancy □ Other (specify)
□ Unknown
Was the birthing person screened for any of the following conditions during this pregnancy?
Check test(s) performed before birth
Yes
Date of screen (mm/dd/yyyy)
No
Unknown
Group B strep
□
/
/
□
□
Hepatitis B (HBsAg)
□
/
/
□
□
Rubella
□
/
/
□
□
Syphilis
□
/
/
□
□
Were any of the following conditions diagnosed for the birthing person during this pregnancy or at the time of labor and delivery?
Yes
Date of diagnosis (mm/dd/yyyy)
No
Unknown
Bacterial vaginosis
□
/
/
□
□
Chlamydia trachomatis infection
□
/
/
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Genital herpes
□
/
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Gonorrhea
□
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Group B strep
□
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Hepatitis B (HBsAg)
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Hepatitis C
□
/
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PID
□
/
/
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Syphilis
□
/
/
□
□
Trichomoniasis
□
/
/
□
□
Were substances used by the birthing person during this pregnancy? □ Yes □ No □ Unknown
Used and injected

Used and did not inject

Used and unknown
if injected

Did not use

Unknown if used

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Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Crack cocaine
Fentanyl
Hallucinogens
Heroin
K2
Marijuana (cannabis, THC, cannabinoids)
Methadone
Methamphetamines
Nicotine (any tobacco)
Opiates
PCP
Other (specify)
Specific drug(s) not documented
CDC 50.42B

Rev. MM/YYYY

(Page 5 of 6)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—

XI. Birthing Person History (for patients exposed perinatally with or without consequent infection) (cont)
Was a toxicology screen done on the birthing person (either during this pregnancy or at the time of delivery)? □ Yes
(If screening for the same substance was done on more than one occasion, record additional dates and results in Comments)
Not screened

Date of screen

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Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Crack cocaine
Fentanyl
Hallucinogens
Heroin
K2
Marijuana (cannabis, THC, cannabinoids)
Methadone
Methamphetamines
Nicotine (any tobacco)
Opiates
PCP
Other (specify)
Specific drug(s) not documented

/

/

/

/

/

/

/

/

/

/

/

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/

/

/

/

/

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/

/

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/

/

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/

□ No □ Unknown

Positive

Negative

Unknown

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□
□
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□
□
□
□
□
□
□
□
□
□
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□

□
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□
□
□
□
□
□
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□
□
□
□
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□
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□

□
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□
□
□
□
□
□
□
□
□
□
□
□
□

XII. Treatment/Services Referrals (record all dates as mm/dd/yyyy)
Has this child ever taken any ARVs?

□ Yes □ No □ Unknown

ARV medication

Date began

Reason for use
HIV Tx PrEP

Date of last use

PEP

PMTCT

HBV Tx

□

□

□

□

□ _________________

/

/

/

/

□

□

□

□

□

□ _________________

/

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/

/

iii.

□

□

□

□

□

□ _________________

/

/

/

/

iv.

□

□

□

□

□

□ _________________

/

/

/

/

v.

□

□

□

□

□

□ _________________

/

/

/

/

i.

□

ii.

Other (specify reason)

(Record additional ARV medications in Comments)
Has this child ever taken PCP prophylaxis
This child’s primary caretaker is

□ Yes □ No □ Unknown Date began

/

/

Date of last use

/

□ 1–Biological parent □ 2–Other relative □ 3–Foster/Adoptive parent, relative □ 4–Foster/Adoptive parent, unrelated
□ 7–Social service agency □ 8–Other (specify in comments) □ 9–Unknown

XIII. Comments

XIV. *Local/Optional Fields

CDC 50.42B

/

Rev. MM/YYYY

(Page 6 of 6)

—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—