Form 50.42A "Adult Hiv Confidential Case Report Form"

What Is Form 50.42A?

This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention on February 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest available edition released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 50.42A by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention.

ADVERTISEMENT
ADVERTISEMENT

Download Form 50.42A "Adult Hiv Confidential Case Report Form"

942 times
Rate (4.3 / 5) 65 votes
Patient Identification
(record all dates as mm/dd/yyyy)
*First Name
*Middle Name
*Last Name
Last Name Soundex
Alternate Name Type (ex: Alias, Married)
*First Name
*Middle Name
*Last Name
*Current Address, Street
Address Date
Address Type
Residential
Bad address
Correctional facility
/
/
Foster home
Homeless
Postal
Shelter
Temporary
*Phone
City
County
State/Country
*ZIP Code
(
)
*Medical Record Number
*Other ID Type
*Number
Adult HIV Confidential Case Report Form
U.S. Department of Health
Centers for Disease Control
and Human Services
and Prevention (CDC)
(Patients >13 years of age at time of diagnosis) *Information NOT transmitted to CDC
Health Department Use Only
(record all dates as mm/dd/yyyy)
Form approved OMB no. 0920-0573 Exp. 06/30/2019
Date Received at Health Department
eHARS Document UID
State Number
/
/
City/County Number
Reporting Health Dept—City/County
Document Source
Surveillance Method
Active
Passive
Follow up
Reabstraction
Unknown
Did this report initiate a new case investigation?
Report Medium
Yes
No
Unknown
1-Field visit
2-Mailed
3-Faxed
4-Phone
5-Electronic transfer
6-CD/disk
Facility Providing Information
(record all dates as mm/dd/yyyy)
Facility Name
*Phone
(
)
*Street Address
City
County
State/Country
*ZIP Code
Facility
Inpatient:
Screening, Diagnostic, Referral Agency
Outpatient:
Private physician’s office
:
Other Facility
:
Emergency room
Type
Hospital
Adult HIV clinic
CTS
STD clinic
Laboratory
Corrections
Unknown
Other, specify
Other, specify
Other, specify
Other, specify
Date Form Completed
*Person Completing Form
*Phone
/
/
(
)
Patient Demographics
(record all dates as mm/dd/yyyy)
Sex Assigned at Birth
Country of Birth
Male
Female
Unknown
US
Other/US dependency (please specify)
Date of Birth
/
/
Alias Date of Birth
/
/
Vital Status
Date of Death
State of Death
1-Alive
2-Dead
/
/
Current Gender Identity
Male
Female
Transgender male-to-female (MTF)
Transgender female-to-male (FTM)
Unknown
Additional gender identity (specify)
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Unknown
Expanded Ethnicity
Race
American Indian/Alaska Native
Asian
Black/African American
Expanded Race
(check all that apply)
Native Hawaiian/Other Pacific Islander
White
Unknown
Residence at Diagnosis
(add additional addresses in Comments) (record all dates as mm/dd/yyyy)
Address Type
(check all that apply to address below)
Residence at HIV diagnosis
Residence at stage 3 (AIDS) diagnosis
Check if SAME as current address
*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. 02/2018
(Page 1 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—
Patient Identification
(record all dates as mm/dd/yyyy)
*First Name
*Middle Name
*Last Name
Last Name Soundex
Alternate Name Type (ex: Alias, Married)
*First Name
*Middle Name
*Last Name
*Current Address, Street
Address Date
Address Type
Residential
Bad address
Correctional facility
/
/
Foster home
Homeless
Postal
Shelter
Temporary
*Phone
City
County
State/Country
*ZIP Code
(
)
*Medical Record Number
*Other ID Type
*Number
Adult HIV Confidential Case Report Form
U.S. Department of Health
Centers for Disease Control
and Human Services
and Prevention (CDC)
(Patients >13 years of age at time of diagnosis) *Information NOT transmitted to CDC
Health Department Use Only
(record all dates as mm/dd/yyyy)
Form approved OMB no. 0920-0573 Exp. 06/30/2019
Date Received at Health Department
eHARS Document UID
State Number
/
/
City/County Number
Reporting Health Dept—City/County
Document Source
Surveillance Method
Active
Passive
Follow up
Reabstraction
Unknown
Did this report initiate a new case investigation?
Report Medium
Yes
No
Unknown
1-Field visit
2-Mailed
3-Faxed
4-Phone
5-Electronic transfer
6-CD/disk
Facility Providing Information
(record all dates as mm/dd/yyyy)
Facility Name
*Phone
(
)
*Street Address
City
County
State/Country
*ZIP Code
Facility
Inpatient:
Screening, Diagnostic, Referral Agency
Outpatient:
Private physician’s office
:
Other Facility
:
Emergency room
Type
Hospital
Adult HIV clinic
CTS
STD clinic
Laboratory
Corrections
Unknown
Other, specify
Other, specify
Other, specify
Other, specify
Date Form Completed
*Person Completing Form
*Phone
/
/
(
)
Patient Demographics
(record all dates as mm/dd/yyyy)
Sex Assigned at Birth
Country of Birth
Male
Female
Unknown
US
Other/US dependency (please specify)
Date of Birth
/
/
Alias Date of Birth
/
/
Vital Status
Date of Death
State of Death
1-Alive
2-Dead
/
/
Current Gender Identity
Male
Female
Transgender male-to-female (MTF)
Transgender female-to-male (FTM)
Unknown
Additional gender identity (specify)
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Unknown
Expanded Ethnicity
Race
American Indian/Alaska Native
Asian
Black/African American
Expanded Race
(check all that apply)
Native Hawaiian/Other Pacific Islander
White
Unknown
Residence at Diagnosis
(add additional addresses in Comments) (record all dates as mm/dd/yyyy)
Address Type
(check all that apply to address below)
Residence at HIV diagnosis
Residence at stage 3 (AIDS) diagnosis
Check if SAME as current address
*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. 02/2018
(Page 1 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—
STATE/LOCAL USE ONLY
*Provider Name (Last, First, M.I.)
*Phone (
)
Hospital/Facility
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
State/Country
*ZIP Code
Facility Type
Hospital
Private physician’s office
Emergency room
Inpatient:
Outpatient:
Screening, Diagnostic, Referral Agency:
Other Facility:
Other, specify
Adult HIV clinic
CTS
STD clinic
Laboratory
Corrections
Unknown
Other, specify
Other, specify
Other, specify
*Provider Name
*Provider Phone (
)
Specialty
Patient History
Pediatric Risk
(respond to all questions) (record all dates as mm/dd/yyyy)
(please enter in Comments)
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
Sex with male
Yes
No
Unknown
Sex with female
Yes
No
Unknown
Injected nonprescription drugs
Yes
No
Unknown
Received clotting factor for hemophilia/coagulation disorder
Yes
No
Unknown
Specify clotting factor:
Date received
/
/
HETEROSEXUAL relations with any of the following:
HETEROSEXUAL contact with intravenous/injection drug user
Yes
No
Unknown
HETEROSEXUAL contact with bisexual male
Yes
No
Unknown
HETEROSEXUAL contact with person with hemophilia/coagulation disorder with documented HIV infection
Yes
No
Unknown
HETEROSEXUAL contact with transfusion recipient with documented HIV infection
Yes
No
Unknown
HETEROSEXUAL contact with transplant recipient with documented HIV infection
Yes
No
Unknown
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)
Yes
No
Unknown
First date received
/
/
Last date received
/
/
Received transplant of tissue/organs or artificial insemination
Yes
No
Unknown
Worked in a healthcare or clinical laboratory setting
Yes
No
Unknown
If occupational exposure is being investigated or considered
as primary mode of exposure, specify occupation and setting:
Other documented risk (please include detail in Comments)
Yes
No
Unknown
Clinical: Acute HIV Infection and Opportunistic Illnesses
(record all dates as mm/dd/yyyy)
Suspect acute HIV infection?
□ Yes
□ No
□ Unknown
If YES, complete the two items below; enter documented negative HIV test data in Laboratory Data section, and
enter patient or provider report of previous negative HIV test in HIV Testing History section.
Clinical signs/symptoms consistent with acute retroviral syndrome (e.g., fever, malaise/fatigue, myalgia, pharyngitis, rash,
□ Yes
□ No
□ Unknown
lymphadenopathy)?
Date of sign/symptom onset
/
/
Other evidence suggestive of acute HIV infection?
If YES, please describe:
□ Yes
□ No
□ Unknown
Date of evidence
/
/
Opportunistic Illnesses
Diagnosis
Dx Date
Diagnosis
Dx Date
Diagnosis
Dx Date
1
Candidiasis, bronchi, trachea, or lungs
Herpes simplex: chronic ulcers (>1 mo.
M. tuberculosis, pulmonary
duration), bronchitis, pneumonitis, or
esophagitis
Candidiasis, esophageal
Histoplasmosis, disseminated or
M. tuberculosis, disseminated or
1
extrapulmonary
extrapulmonary
Carcinoma, invasive cervical
Isosporiasis, chronic intestinal (>1 mo.
Mycobacterium, of other/unidentified
duration)
species, disseminated or extrapulmonary
Coccidioidomycosis, disseminated or
Kaposi’s sarcoma
Pneumocystis pneumonia
extrapulmonary
Cryptococcosis, extrapulmonary
Lymphoma, Burkitt’s (or equivalent)
Pneumonia, recurrent, in 12 mo. period
Cryptosporidiosis, chronic intestinal (>1
Lymphoma, immunoblastic (or equivalent)
Progressive multifocal
mo. duration)
leukoencephalopathy
Cytomegalovirus disease (other than in
Lymphoma, primary in brain
Salmonella septicemia, recurrent
liver, spleen, or nodes)
Cytomegalovirus retinitis (with loss of
Mycobacterium avium complex or M.
Toxoplasmosis of brain, onset at >1 mo.
vision)
kansasii, disseminated or extrapulmonary
of age
HIV encephalopathy
Wasting syndrome due to HIV
1
If a diagnosis date is entered for either tuberculosis diagnosis above, provide RVCT Case Number:
CDC 50.42A
Rev. 02/2018
(Page 2 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—
Laboratory Data
(record additional tests and tests not specified below in Comments) (record all dates as mm/dd/yyyy)
HIV Immunoassays (Nondifferentiating)
TEST 1
HIV-1 IA
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-1 WB
HIV-1 IFA
HIV-2 IA
HIV-2 WB
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result
Positive
Negative
Indeterminate
Collection Date
/
/
Point-of-care rapid test
TEST 2
HIV-1 IA
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-1 WB
HIV-1 IFA
HIV-2 IA
HIV-2 WB
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result
Collection Date
Point-of-care rapid test
Positive
Negative
Indeterminate
/
/
HIV Immunoassays (Differentiating)
HIV-1/2 type-differentiating immunoassay
Role of test in diagnostic algorithm
(differentiates between HIV-1 Ab and HIV-2 Ab)
Screening/initial test
Confirmatory/supplemental test
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
1
Result
HIV-1 positive
HIV-2 positive
HIV positive, untypable
HIV-2 positive with HIV-1 cross-reactivity
Overall interpretation:
HIV-1 indeterminate
HIV-2 indeterminate
HIV indeterminate
HIV negative
Analyte results: HIV-1 Ab:
Positive
Negative
Indeterminate Collection Date
/
/
Point-of-care rapid test
1
HIV-2 Ab:
Positive
Negative
Indeterminate
Always complete the overall interpretation. Complete the analyte results when available.
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
Ag positive
Ab positive
Both (Ag and Ab positive)
Negative
Invalid
Collection Date
/
/
Point-of-care rapid 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 __________________________________________________
2
Result
Index value _____________
Overall interpretation:
Reactive
Nonreactive
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
2
Collection Date
/
/
Point-of-care rapid test
Complete the overall interpretation and the analyte results.
HIV Detection Tests (Qualitative)
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
/
/
HIV Detection Tests (Quantitative viral load)
Note: Include earliest test at or after diagnosis.
TEST 1
HIV-1 RNA/DNA NAAT (Quantitative viral load)
HIV-2 RNA/DNA NAAT (Quantitative viral load)
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result
Detectable
Undetectable Copies/mL ______________________________ Log _____________ Collection Date
/
/
TEST 2
HIV-1 RNA/DNA NAAT (Quantitative viral load)
HIV-2 RNA/DNA NAAT (Quantitative viral load)
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Result
Undetectable Copies/mL ______________________________ Log _____________ Collection Date
Detectable
/
/
Drug Resistance Tests (Genotypic)
TEST
Test brand name/Manufacturer ____________________________________
HIV-1 Genotype (Unspecified)
Lab name _______________________________________________________ Facility name ___________________________________________________
Provider name __________________________________________________ Collection Date
/
/
Immunologic Tests (CD4 count and percentage)
CD4 at or closest to diagnosis: CD4 count
cells/µL CD4 percentage
%
Collection Date
/
/
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
First CD4 result <200 cells/µL or <14%: CD4 count
cells/µL CD4 percentage
Collection Date
%
/
/
Test brand name/Manufacturer _____________________________________ Lab name ______________________________________________________
Facility name ____________________________________________________ Provider name __________________________________________________
Other CD4 result: 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 for this algorithm
/
/
Complete the above only if none of the following was positive: HIV-1 Western blot, IFA, culture, viral load, or qualitative NAAT [RNA or DNA]
If HIV laboratory tests were not documented, is HIV diagnosis documented by a physician?
Yes
No
Unknown
If YES, provide date of diagnosis
/
/
Date of last documented negative HIV test (before HIV diagnosis date)
/
/
Specify type of test:
CDC 50.42A
Rev. 02/2018
(Page 3 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—
Treatment/Services Referrals
(record all dates as mm/dd/yyyy)
Has this patient been informed of his/her HIV infection?
This patient’s partners will be notified about their HIV exposure and counseled by
Yes
No
Unknown
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?
Has this patient delivered live-born infants?
obstetrical services
Yes
No
Unknown
Yes
No
Unknown
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
*Phone
(if child was born at home, enter “home birth”)
(
)
Facility Type
Inpatient:
Outpatient:
Other Facility
:
Emergency room
Hospital
Other, specify
Corrections
Unknown
Other, specify
Other, specify
*Street Address
*ZIP Code
City
County
State/Country
Antiretroviral Use History
(record all dates as mm/dd/yyyy)
Main source of antiretroviral (ARV) use information (select one)
Date patient reported information
Patient interview
Medical record review
Provider report
NHM&E
Other
/
/
☐ Unknown
Ever taken any ARVs? ☐ Yes
☐ No
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
/
/
Other (specify reason)
ARV medications
Date began
/
/
Date of last use
/
/
HIV Testing History
(record all dates as mm/dd/yyyy)
Main source of testing history information (select one)
Date patient reported information
Patient interview
Medical record review
Provider report
NHM&E
Other
/
/
Ever had previous positive HIV test?
Yes
No
Unknown
Date of first positive HIV test
/
/
Ever had a negative HIV test?
Yes
No
Unknown
Date of last negative HIV test (if date is from
a lab test with test type, enter in Lab Data section)
/
/
Number of negative HIV tests within the 24 months before the first positive test
Unknown
Comments
*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 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 50.42A
Rev. 02/2018
(Page 4 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—
Page of 4