Adult HIV Confidential Case Report Form

National HIV Surveillance System (NHSS)

Attachment 3(a)
Adult HIV Confidential Case Report Form

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

*Middle Name

Alternate Name Type (ex: Alias, Married)

*Last Name

*First Name

Address Type □ Residential

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

*Phone
City
(
)
*Medical Record Number

Last Name Soundex

*Middle Name

*Last Name

*Current Address, Street

Address Date
/

County

State/Country
*Other ID Type

*Number

Adult HIV Confidential Case Report Form

U.S. Department of Health
and Human Services

(Patients >13 years of age 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
/
/

/

*ZIP Code

Centers for Disease Control
and Prevention (CDC)

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

eHARS Document UID

State Number
City/County Number

Reporting Health Dept—City/County

□ Active

Document Source

Surveillance Method

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

Report Medium
□ 1-Field visit □ 2-Mailed

□ Passive

□ Follow up

□ 3-Faxed □ 4-Phone

□ Reabstraction

□ 5-Electronic transfer

□ Unknown
□ 6-CD/disk

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

*Phone
(
)

*Street Address
City
Facility
Type

County

State/Country

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

Inpatient:

□ Hospital
□ Other, specify

Date Form Completed

/

*ZIP Code

Screening, Diagnostic, Referral Agency:

□ CTS □ STD clinic
□ Other, specify

*Person Completing Form

/

□ Emergency room
□ Laboratory □ Corrections □ Unknown
□ Other, specify

Other Facility:

*Phone
(
)

IV. Patient Demographics (record all dates as mm/dd/yyyy)
Sex Assigned at Birth
Date of Birth

/

□ Male □ Female □ Unknown

Country of Birth

Alias Date of Birth

/

□ 1-Alive □ 2-Dead
Date of Death
Gender Identity
□ Man □ Woman □ Transgender man
□ Additional gender identity (specify)
□ Declined to answer □ Unknown
Vital Status

Date Identified

Sexual Orientation

Date Identified

□ US □ Other/US dependency (specify)

/

/

/

/

/

/

□ Transgender woman

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

/

/

State of Death

□ Bisexual

Ethnicity

□ Hispanic/Latino □ Not Hispanic/Latino □ Unknown

Race
(check all that apply)

□ American Indian/Alaska Native
□ Asian □ Black/African American Expanded Race
□ Native Hawaiian/Other Pacific Islander
□ White □ Unknown

Expanded Ethnicity

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 3 (AIDS) diagnosis □ Check if SAME as 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.
CDC 50.42A

Rev. MM/YYYY (Page 1 of 4)

—ADULT 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)

□ Check if SAME as facility providing information

Facility Name

*Phone (

)

*Street Address
County

City
Facility Type

Inpatient: □ Hospital
□ Other, specify

State/Country

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

*Provider Name

*Provider Phone (

*ZIP Code

Screening, Diagnostic, Referral Agency:
□ CTS □ STD clinic
□ Other, specify

Other Facility: □ Emergency room
□ Laboratory □ Corrections □ Unknown
□ Other, specify

Specialty

)

□ Pediatric Risk (enter in Comments)

VII. Patient History (respond to all questions) (record all dates as mm/dd/yyyy)
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
Sex with male
Sex with female
Injected nonprescription drugs
Received clotting factor for hemophilia/coagulation disorder
Specify clotting factor:

Date received

/

/

□ Yes
□ Yes
□ Yes
□ Yes

□ No
□ No
□ No
□ No

□ Unknown
□ Unknown
□ Unknown
□ Unknown

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

□ No
□ No
□ No
□ No
□ No
□ No
□ No

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

□ Yes
□ Yes

□ No
□ No

□ Unknown
□ Unknown

□ Yes

□ No

□ Unknown

HETEROSEXUAL relations with any of the following:
HETEROSEXUAL contact with person who injected drugs
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
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
Worked in a healthcare or clinical laboratory setting
If occupational exposure is being investigated or considered
as primary mode of exposure, specify occupation and setting:

________________________________________________

Other documented risk (include detail in Comments) __________________________________________________________

VIII. Clinical: Acute HIV Infection and Opportunistic Illnesses (record all dates as mm/dd/yyyy)
Suspect acute HIV infection? If YES, complete the two items below; enter documented negative HIV test result data in Laboratory Data section,

□ Yes □ No □ Unknown

Clinical signs/symptoms consistent with acute retroviral syndrome (e.g., fever, malaise/fatigue, myalgia, pharyngitis, rash,
lymphadenopathy)? Date of sign/symptom onset
/
/
Other evidence suggestive of acute HIV infection? If YES, describe: _________________________________________________
Date of evidence
/
/
_________________________________________________
Opportunistic Illnesses

□ Yes □ No □ Unknown

and enter patient or provider report of previous negative HIV test result in HIV Testing History section

Diagnosis

Dx Date

Diagnosis

Dx Date

□ Yes □ No □ Unknown

Diagnosis

Candidiasis, bronchi, trachea, or lungs

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

M. tuberculosis, pulmonary1

Candidiasis, esophageal

Histoplasmosis, disseminated or extrapulmonary

M. tuberculosis, disseminated or
extrapulmonary1

Carcinoma, invasive cervical

Isosporiasis, chronic intestinal (>1 mo. duration)

Mycobacterium, of other/unidentified species,
disseminated or extrapulmonary

Coccidioidomycosis, disseminated or
extrapulmonary

Kaposi’s sarcoma

Pneumocystis pneumonia

Cryptococcosis, extrapulmonary

Lymphoma, Burkitt’s (or equivalent)

Pneumonia, recurrent, in 12 mo. period

Cryptosporidiosis, chronic intestinal (>1 mo.
duration)

Lymphoma, immunoblastic (or equivalent)

Progressive multifocal leukoencephalopathy

Cytomegalovirus disease (other than in liver,
spleen, or nodes)

Lymphoma, primary in brain

Salmonella septicemia, recurrent

Cytomegalovirus retinitis (with loss of vision)

Mycobacterium avium complex or M. kansasii,
disseminated or extrapulmonary

Toxoplasmosis of brain, onset at >1 mo. of
age

HIV encephalopathy
1If

Dx Date

Wasting syndrome due to HIV

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

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
CDC 50.42A

Rev. MM/YYYY (Page 2 of 4)

—ADULT 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)
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 __________________________________________________
Result 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 __________________________________________________
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
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
HIV Detection Tests
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 _________________________________________________
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 HIV infection diagnosis documented by a physician rather than by laboratory test results? □ Yes □ No □ Unknown
If YES, provide date of diagnosis by physician
/
/
Date of last documented negative HIV test result (before HIV diagnosis date)
/
/
Specify type of test: _____________________________________________
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider2 □ Lab test, self-collected sample
2Results

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

CDC 50.42A

Rev. MM/YYYY (Page 3 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—

X. Treatment/Services Referrals (record all dates as mm/dd/yyyy)
Has this patient been informed of his/her HIV infection?
□ Yes □ No □ Unknown

This patient’s partners will be notified about their HIV exposure and counseled by
□ 1-Health dept □ 2-Physician/Provider □ 3-Patient □ 9-Unknown

Evidence of receipt of HIV medical care other than laboratory test result (select one; record additional evidence in Comments)
□ 1-Yes, documented □ 2-Yes, client self-report, only Date of medical visit or prescription
/
/

For Female Patient

This patient is receiving or has been referred for gynecological or Is this patient currently pregnant?
obstetrical services □ Yes □ No □ Unknown
□ Yes □ No □ Unknown

Has this patient delivered live-born infants?
□ Yes □ No □ Unknown

For Children of Patient (record most recent birth in these boxes; record additional or multiple births in Comments)
*Child’s Name

Child’s Date of Birth

Child’s Last Name Soundex

/

/

Child’s State Number

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

*Phone
(
)

□ Emergency room
□ Corrections □ Unknown
□ Other, specify

Outpatient:

□ Hospital
□ Other, specify

Other Facility:

□ Other, specify

*Street Address

*ZIP Code

City

County

State/Country

XI. Antiretroviral Use History (record all dates as mm/dd/yyyy)
Main source of antiretroviral (ARV) use information (select one)
□ Patient interview
□ Medical record review
□ Provider report
Ever taken any ARVs? ☐ Yes

☐ No

□ NHM&E

☐ Unknown

Date patient reported information
/
/

□ Other

If yes, reason for ARV use (select all that apply)

□
□
□
□
□
□

HIV Tx

ARV medications

Date began

/

/

Date of last use

/

/

PrEP

ARV medications

Date began

/

/

Date of last use

/

/

PEP

ARV medications

Date began

/

/

Date of last use

/

/

PMTCT

ARV medications

Date began

/

/

Date of last use

/

/

HBV Tx

ARV medications

Date began

/

/

Date of last use

/

/

Date began

/

/

Date of last use

/

/

Other (specify reason)
ARV medications

XII. HIV Testing History (record all dates as mm/dd/yyyy)
Main source of testing history information (select one)
□ Patient interview □ Medical record review □ Provider report
Ever had previous positive HIV test result?

□ Yes

□ No

□ NHM&E

□ Unknown

Was the first positive test result from a self-test performed by the patient?
Ever had a negative HIV test result?

□ Yes

□ No

Date patient reported information
/
/

□ Other
Date of first positive HIV test result

/

/

□ Yes □ No □ Unknown

□ Unknown

Date of last negative HIV test result (if date is from
a lab test with test type, enter in Lab Data section)
Was the last negative test result from a self-test performed by the patient? □ Yes □ No □ Unknown
Number of negative HIV test results within the 24 months before the first positive test result
How many of these negative test results were from self-tests performed by the patient?

/

/

□ Unknown
□ Unknown

XIII. Comments

XIV. *Local/Optional Fields

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 50.42A

Rev. MM/YYYY (Page 4 of 4)

—ADULT HIV CONFIDENTIAL CASE REPORT—