"Adult Hiv Confidential Case Report Form" - Connecticut

Adult Hiv Confidential Case Report Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

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Adult HIV
Confidential
Case Report Form
(Patients ≥13 years of age at diagnosis)
Prior Dx
Surveillance Method
Report Source
STATE #
HARMS #
WEEK
YEAR
LexNex
 P
 F
 U
YR:
Site:
A
20___
PATIENT IDENTIFIER INFORMATION
MR #________________________________ SSN #_______________________________
Patient Name:
Phone: (
) _______ -
(LAST, FIRST, MI)
Address:
City:
County:
State: ____ Zip: ______
PROVIDER INFORMATION
Provider Name:
Phone: (
) _______ -
Facility:
City:
State:
Zip:
FORM INFORMATION
Date Completed: ___/___/______ Person reporting:
Phone: (
)
-
DEMOGRAPHIC INFORMATION
Date of Birth:
Date of Death:
Diagnostic Status:
Current Status:
State/Terr Death:





/
/
/
/
HIV Infection
AIDS
Alive
Dead
Unkn
Race: (select one or more)
Current Gender Identity:
Ethnicity: (select one)
Country of Birth:
Sex at birth:




Male
Female
Hispanic/Latino

Black or African Am
White
Asian
US

Male


Trans Male-to-Female
Not Hispanic/Latino

Other _______________
American Indian/Alaskan

Female


Trans Female-to-Male
Unknown
Unknown
Unknown


Hawaiian/Other Pacific Islander
Unkn
Residence at Diagnosis: Same as CURRENT address
City:______________________________________ County: FFLD HTFD LITCH NH NL MDX TLND WIND State: _________ Zip: _____________
FACILITY OF DIAGNOSIS
RISK FACTOR HISTORY
st
Facility Name:
Before the 1
positive HIV test, this patient had:


Sex with male
Sex with female
Injected drugs:
Yes
No
Unknown
 Inpatient  Outpatient  Other________________

:
Other
City:
HETEROSEXUAL relations with the following:



IDU
Bisexual male
Person with documented HIV infection
State/Country:


Person w/ hemophilia
Transfusion/transplant recipient
Date of transfusion or transplant:
/
/
 Lab Report  Lab Audit
Identification Method:

Worked in health-care or clinical lab setting
 Viral Load  ICD-9  Other:

Congenital
Report Medium: Paper: Field
 Mail
 Faxed

NO IDENTIFIED RISK (NIR)
 Phoned  Electronic transfer Disc
ANTIRETROVIRAL USE HISTORY
HIV TESTING HISTORY
Has the patient ever used antiretroviral medicines?
 YES
 NO
 UNKN
Source:  Patient  Interview  Chart abstraction
 Provider report  CW/XPEMS  Other
ARV Use Type
ARV Medication
Date Began
Date last used
HIV Tx
Date patient answered questions: _____/____/______
PrEP
Ever had a previous positive HIV test?
 Yes
 No
 Unknown
PEP
Date of first positive HIV test:
_____/____/______
PMTCT
Has the patient ever had a negative HIV test?
HBV Tx
 Yes
 No
 Unknown
Other
Date of the LAST negative HIV test: _____/____/______
(HIV Tx – HIV treatment; PrEP - PRE-exposure prophylaxis; PEP - POST-exposure
Number of HIV tests in the past 2 years: ___________
prophylaxis; PMTCT - prevention of mother-to-child transmission;
HBV Tx – Hepatitis B treatment)
Adult HIV
Confidential
Case Report Form
(Patients ≥13 years of age at diagnosis)
Prior Dx
Surveillance Method
Report Source
STATE #
HARMS #
WEEK
YEAR
LexNex
 P
 F
 U
YR:
Site:
A
20___
PATIENT IDENTIFIER INFORMATION
MR #________________________________ SSN #_______________________________
Patient Name:
Phone: (
) _______ -
(LAST, FIRST, MI)
Address:
City:
County:
State: ____ Zip: ______
PROVIDER INFORMATION
Provider Name:
Phone: (
) _______ -
Facility:
City:
State:
Zip:
FORM INFORMATION
Date Completed: ___/___/______ Person reporting:
Phone: (
)
-
DEMOGRAPHIC INFORMATION
Date of Birth:
Date of Death:
Diagnostic Status:
Current Status:
State/Terr Death:





/
/
/
/
HIV Infection
AIDS
Alive
Dead
Unkn
Race: (select one or more)
Current Gender Identity:
Ethnicity: (select one)
Country of Birth:
Sex at birth:




Male
Female
Hispanic/Latino

Black or African Am
White
Asian
US

Male


Trans Male-to-Female
Not Hispanic/Latino

Other _______________
American Indian/Alaskan

Female


Trans Female-to-Male
Unknown
Unknown
Unknown


Hawaiian/Other Pacific Islander
Unkn
Residence at Diagnosis: Same as CURRENT address
City:______________________________________ County: FFLD HTFD LITCH NH NL MDX TLND WIND State: _________ Zip: _____________
FACILITY OF DIAGNOSIS
RISK FACTOR HISTORY
st
Facility Name:
Before the 1
positive HIV test, this patient had:


Sex with male
Sex with female
Injected drugs:
Yes
No
Unknown
 Inpatient  Outpatient  Other________________

:
Other
City:
HETEROSEXUAL relations with the following:



IDU
Bisexual male
Person with documented HIV infection
State/Country:


Person w/ hemophilia
Transfusion/transplant recipient
Date of transfusion or transplant:
/
/
 Lab Report  Lab Audit
Identification Method:

Worked in health-care or clinical lab setting
 Viral Load  ICD-9  Other:

Congenital
Report Medium: Paper: Field
 Mail
 Faxed

NO IDENTIFIED RISK (NIR)
 Phoned  Electronic transfer Disc
ANTIRETROVIRAL USE HISTORY
HIV TESTING HISTORY
Has the patient ever used antiretroviral medicines?
 YES
 NO
 UNKN
Source:  Patient  Interview  Chart abstraction
 Provider report  CW/XPEMS  Other
ARV Use Type
ARV Medication
Date Began
Date last used
HIV Tx
Date patient answered questions: _____/____/______
PrEP
Ever had a previous positive HIV test?
 Yes
 No
 Unknown
PEP
Date of first positive HIV test:
_____/____/______
PMTCT
Has the patient ever had a negative HIV test?
HBV Tx
 Yes
 No
 Unknown
Other
Date of the LAST negative HIV test: _____/____/______
(HIV Tx – HIV treatment; PrEP - PRE-exposure prophylaxis; PEP - POST-exposure
Number of HIV tests in the past 2 years: ___________
prophylaxis; PMTCT - prevention of mother-to-child transmission;
HBV Tx – Hepatitis B treatment)
Acute
Laboratory Data
HIV Antibody Tests (Non-type-differentiating)
RESULT
COLLECTION DATE



Test 1:
HIV-1 IA
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-2 IA
Positive/Reactive
Negative/Nonreactive
/
/

Other __________________________


Indeterminate
Rapid test?
Yes
No
HIV Antibody Tests (Type-differentiating)

HIV-1
HIV-2
Both HIV-1 and HIV-2
Other ___________________


/
/
Test 2:
Multispot
Geenius
Neither (negative)
Indeterminate
HIV Detection Tests (Quantitative)



Other ____________
/
/
Undetectable
Det: ________________ c/mL
Test 3:
HIV-1 RNA
HIV-1 DNA NAAT
HIV Detection Tests (Qualitative)

Positive/Reactive
Negative/Nonreactive
Test 3:
 HIV-1 RNA/DNA NAAT  HIV-1 Culture  HIV-1 P24 Antigen
/
/
 HIV-2 RNA/DNA NAAT  HIV-2 Culture
Indeterminate
Why was the patient tested for HIV?
 Symptoms/dx w/ OI
 Routine test
Pre-exposure medication (PrEP) screening Rule out HIV
 ‘Just checking’
 Partner dx w/ HIV
 Regular tester
 Dx with STD
 Prenatal screening
 Establish Care
Other:
Immunologic Testing:
HIV Genotype done?
COLLECTION DATE
/
/
Closest to current diagnostic status:
COLLECTION DATE
 YES, Lab:__________________________  No
CD4 count ________ cells/ul ______%
/
/
Physician Diagnosis:
FIRST <200 or <14% of total lymphocytes:
If HIV lab tests were not available, is HIV
CD4 count ________ cells/ul ______%
/
/
Yes
No
diagnosis documented by a physician?
Clinical Status
If YES, provide date of documentation:
/
/
Initial
Clinical Record Reviewed?

Yes

No
Referrals
Dx Date
AIDS INDICATOR DISEASES:
(mo/day/yr)
Has the patient been informed
Yes  No  Unkn
of their HIV results?
/
/
Candidiasis, esophageal
/
/
Kaposi’s sarcoma
This patient’s medical
This patient’s partners will be
treatment is primarily
/
/
M. tuberculosis
notified about their HIV
reimbursed by:
/
/
Pneumocystis jiroveci pneumonia
exposure and counseled by:
Medicaid Medicare
Pneumonia, recurrent
/
/
Private insurance
Physician/provider
No coverage
/
/
Toxoplasmosis of brain
Patient
Other public funding
/
/
Wasting syndrome due to HIV
Unknown
Clinical trial/program
/
/
Other:
Not applicable
Unknown
For Female Patients
Where was the patient referred for HIV Care?
Is patient receiving or been
Yes  No  Unkn
Provider Name:___________________________________
referred for OB/GYN services?
Facility: _________________________________________
Yes  No  Unkn
Is this patient currently pregnant?
Health care providers can request assistance for
If ‘YES’, when is the due date?
/
/
notification of potentially exposed partners.
Hospital:
Where is the patient scheduled to
Would you like this assistance from DPH?
Yes
No
deliver?
Comments:
______________________________________________________________________________________________________
________________________________________________________________________________________________________________
______________________________________________________________________________________________________________
4.16
Mail completed form: CT Department of Public Health · 410 Capitol Ave, #11 ASV · Hartford, CT 06134 | Fax completed form: (860) 509-8237
For questions about this form or HIV reporting: p: (860) 509-7900 · e: hivsurveillance.dph@ct.gov
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