State Form 51201 "Adult Hiv/Aids Confidential Case Report" - Indiana

What Is State Form 51201?

This is a legal form that was released by the Indiana State Department of Health - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the Indiana State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of State Form 51201 by clicking the link below or browse more documents and templates provided by the Indiana State Department of Health.

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Download State Form 51201 "Adult Hiv/Aids Confidential Case Report" - Indiana

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I. PATIENT INFORMATION
Patient’s Name (Last, First, M.I.):
________________________________________________________________________________________________ Telephone Number: (
) ___________________________________
ZIP
Address:
_________________________________________________ City: _________________________________ County:
__________________ State: ___________ Code:
____________________________
Social Security Number*: ________________________________________
- Patient identifier information is not transmitted to CDC! -
RETURN TO STATE/LOCAL HEALTH DEPARTMENT
* This agency is requesting disclosure of your Social Security Number (SSN) in accordance with IC 16-41-2; disclosure is voluntary and you will not be penalized for refusal.
INDIANA STATE DEPARTMENT OF HEALTH
II. STATE HEALTH DEPARTMENT USE ONLY
ADULT HIV/AIDS CONFIDENTIAL CASE REPORT
(Patients >13 years of age at time of diagnosis)
State Patient
Number:
State Form 51201 (R3 / 10-13)
Date Form Completed:_____/_______/_______
III. DEMOGRAPHIC INFORMATION
DIAGNOSTIC STATUS
AGE AT
DATE OF BIRTH:
CURRENT STATUS:
DATE OF DEATH:
STATE/TERRITORY OF DEATH:
AT REPORT: (check one)
DIAGNOSIS:
Month
Day
Year
Month
Day
Year
Alive
Dead
Years
HIV Infection (not AIDS)
___________________________
Years
AIDS
SEX (at birth):
ETHNICITY (select one):
RACE (select one or more):
COUNTRY OF BIRTH:
Male
U.S.
Hispanic or Latino
Black or
American Indian or Alaska Native
Asian
African American
Female
Not Hispanic or Latino
U.S. Dependencies and Possessions (incl. Puerto Rico)
Native Hawaiian/or Other Pacific Islander
White
Multiracial
Transgendered
(specify) ___________________________________________
Unknown
Male to
Other
Female
(specify): ______________________________
Female to
Height:
_______________ Weight:
_______________
Male
RESIDENCE AT DIAGNOSIS:
City: ______________________________________________ County: _________________________________________
State/Country: __________________________________ ZIP Code:
-
DIAGNOSED OR TREATED IN ANY OTHER STATE(S)/COUNTRY?:
State: ____________________________________________________________ Country: _______________________________________________________________________
IV. FACILITY OF FIRST DIAGNOSIS
V. PHYSICIAN/PROVIDER COMPLETING FORM
______________________________________________________________
Current Physician/Provider
Facility Name
Telephone
______________________________________________________________
Name: ___________________________________________
Number: _________________________
City
State/Country
(Last, First, MI)
Name of Facility
Medical
FACILITY TYPE (check one)
or Practice: _______________________________________
Record Number: ___________________
Physician, HMO
Prenatal/OB clinic
Complete Address: ___________________________________________________________________
Case Management Agency
Correction facility
HRSA Clinic
Hospital, Inpatient
City_________________________ State _____________ ZIP ________________
Counseling & Testing Site
Hospital, Outpatient
Person
Telephone
Drug treatment center
Other (specify):
Completing Form: ____________________________________ Number: ______________________
______________________
- Physician identifier information is not transmitted to CDC! -
VI. PATIENT HISTORY
BEFORE THE FIRST POSITIVE HIV TEST OR AIDS DIAGNOSIS, THIS PERSON HAD:
(Respond to ALL categories.)
Yes
No
Sex with male ……………………………………………………………………………………………………………...........................................................................................
Sex with female ……………………………………………………………………………………………………………………………………………………………………………
Injected nonprescription drugs …………………………………………………………………………………………………………………………………………..….…………..
Worked in a health-care or clinical laboratory setting …………………………………… (specify occupation) _________________________
Received transfusion of blood/blood components (other than clotting factor)………………………………………………………………………………………………………
First ____/____
Last ____/____
Mo
Yr
Mo
Yr
Received transplant of tissue/organs or artificial insemination………………………………………………………………………………………………………………………
Received clotting factor for hemophilia/coagulation disorder ………………………………………………………………………………..……………………………………….
Specify disorder:
Factor VIII (Hemophilia A)
Factor IX (Hemophilia B)
Other (Specify) ____________________________
HETEROSEXUAL relations with any of the following:
Yes
No
Unk
Intravenous/injection drug user …………………………………………………………………………………………………………………………………………………….…….
Bisexual male……………………………………………………………………………………………………………………………………………………….………………………
Person with hemophilia/coagulation disorder ………………………………………………………………………………………………………………………………………….
Transfusion recipient with documented HIV infection …………………………………………………………………………………………………………………………………
Transplant recipient with documented HIV infection, risk not specified …………………………………………………………………………………………………………….
Person with AIDS or documented HIV infection, risk not specified………………………………………………………………………………………………………………….
I. PATIENT INFORMATION
Patient’s Name (Last, First, M.I.):
________________________________________________________________________________________________ Telephone Number: (
) ___________________________________
ZIP
Address:
_________________________________________________ City: _________________________________ County:
__________________ State: ___________ Code:
____________________________
Social Security Number*: ________________________________________
- Patient identifier information is not transmitted to CDC! -
RETURN TO STATE/LOCAL HEALTH DEPARTMENT
* This agency is requesting disclosure of your Social Security Number (SSN) in accordance with IC 16-41-2; disclosure is voluntary and you will not be penalized for refusal.
INDIANA STATE DEPARTMENT OF HEALTH
II. STATE HEALTH DEPARTMENT USE ONLY
ADULT HIV/AIDS CONFIDENTIAL CASE REPORT
(Patients >13 years of age at time of diagnosis)
State Patient
Number:
State Form 51201 (R3 / 10-13)
Date Form Completed:_____/_______/_______
III. DEMOGRAPHIC INFORMATION
DIAGNOSTIC STATUS
AGE AT
DATE OF BIRTH:
CURRENT STATUS:
DATE OF DEATH:
STATE/TERRITORY OF DEATH:
AT REPORT: (check one)
DIAGNOSIS:
Month
Day
Year
Month
Day
Year
Alive
Dead
Years
HIV Infection (not AIDS)
___________________________
Years
AIDS
SEX (at birth):
ETHNICITY (select one):
RACE (select one or more):
COUNTRY OF BIRTH:
Male
U.S.
Hispanic or Latino
Black or
American Indian or Alaska Native
Asian
African American
Female
Not Hispanic or Latino
U.S. Dependencies and Possessions (incl. Puerto Rico)
Native Hawaiian/or Other Pacific Islander
White
Multiracial
Transgendered
(specify) ___________________________________________
Unknown
Male to
Other
Female
(specify): ______________________________
Female to
Height:
_______________ Weight:
_______________
Male
RESIDENCE AT DIAGNOSIS:
City: ______________________________________________ County: _________________________________________
State/Country: __________________________________ ZIP Code:
-
DIAGNOSED OR TREATED IN ANY OTHER STATE(S)/COUNTRY?:
State: ____________________________________________________________ Country: _______________________________________________________________________
IV. FACILITY OF FIRST DIAGNOSIS
V. PHYSICIAN/PROVIDER COMPLETING FORM
______________________________________________________________
Current Physician/Provider
Facility Name
Telephone
______________________________________________________________
Name: ___________________________________________
Number: _________________________
City
State/Country
(Last, First, MI)
Name of Facility
Medical
FACILITY TYPE (check one)
or Practice: _______________________________________
Record Number: ___________________
Physician, HMO
Prenatal/OB clinic
Complete Address: ___________________________________________________________________
Case Management Agency
Correction facility
HRSA Clinic
Hospital, Inpatient
City_________________________ State _____________ ZIP ________________
Counseling & Testing Site
Hospital, Outpatient
Person
Telephone
Drug treatment center
Other (specify):
Completing Form: ____________________________________ Number: ______________________
______________________
- Physician identifier information is not transmitted to CDC! -
VI. PATIENT HISTORY
BEFORE THE FIRST POSITIVE HIV TEST OR AIDS DIAGNOSIS, THIS PERSON HAD:
(Respond to ALL categories.)
Yes
No
Sex with male ……………………………………………………………………………………………………………...........................................................................................
Sex with female ……………………………………………………………………………………………………………………………………………………………………………
Injected nonprescription drugs …………………………………………………………………………………………………………………………………………..….…………..
Worked in a health-care or clinical laboratory setting …………………………………… (specify occupation) _________________________
Received transfusion of blood/blood components (other than clotting factor)………………………………………………………………………………………………………
First ____/____
Last ____/____
Mo
Yr
Mo
Yr
Received transplant of tissue/organs or artificial insemination………………………………………………………………………………………………………………………
Received clotting factor for hemophilia/coagulation disorder ………………………………………………………………………………..……………………………………….
Specify disorder:
Factor VIII (Hemophilia A)
Factor IX (Hemophilia B)
Other (Specify) ____________________________
HETEROSEXUAL relations with any of the following:
Yes
No
Unk
Intravenous/injection drug user …………………………………………………………………………………………………………………………………………………….…….
Bisexual male……………………………………………………………………………………………………………………………………………………….………………………
Person with hemophilia/coagulation disorder ………………………………………………………………………………………………………………………………………….
Transfusion recipient with documented HIV infection …………………………………………………………………………………………………………………………………
Transplant recipient with documented HIV infection, risk not specified …………………………………………………………………………………………………………….
Person with AIDS or documented HIV infection, risk not specified………………………………………………………………………………………………………………….
VII. LABORATORY DATA
Test 1:
HIV-1 RNA/DNA NAAT (Qual)
HIV-1 P24 Antigen
HIV-1 Culture □ HIV-2 RNA/DNA NAAT (Qual)
HIV-2 Culture
EIA ½
IFA
Western Blot
Qualitative differentiated Immunoassay (i.e.Multispot )
Result :
Positive/Reactive
Negative/Nonreactive
Indeterminate Collection Date: __ __ /__ __ /__ __ __ __
Test 2:
HIV-1 RNA/DNA NAAT (Qual)
HIV-1 P24 Antigen
HIV-1 Culture □ HIV-2 RNA/DNA NAAT (Qual)
HIV-2 Culture
EIA ½
IFA
Western Blot
Qualitative differentiated Immunoassay (i.e.Multispot )
Result :
Positive/Reactive
Negative/Nonreactive
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)
Result:
Detectable
Undetectable Copies/mL: _________________ Log: ______________ Collection Date: __ __ /__ __ /__ __ __ __
Test 2:
HIV-1 RNA/DNA NAAT (Quantitative viral load)
Result:
Detectable
Undetectable Copies/mL: _________________ Log: ______________ Collection Date: __ __ /__ __ /__ __ __ __
Immunologic Tests (CD4 count and percentage)
CD4 at or closest to current diagnostic status: CD4 count: _________cells/μL CD4 percentage: ____% Collection Date: __ __ /__ __ /__ __ __ __
First CD4 result <200 cells/μL or <14%: CD4 count: _______________cells/μL CD4 percentage: ____% Collection Date: __ __ /__ __ /__ __ __ __
Documentation of Tests
Complete below only if none of the following was positive: HIV-1 Western blot, IFA, culture, p24 Ag test, viral load, or qualitative NAAT [RNA or DNA]:
Did documented laboratory test results meet approved HIV diagnostic algorithm criteria?
Yes
No
Unknown
If YES, provide date (specimen collection date if known) of earliest positive test for this algorithm: __ __ /__ __ /__ __ __ __
If HIV laboratory tests were not documented, is HIV diagnosis documented by a physician prior to 2006?
Yes
No If YES, provide date of diagnosis: __ __ /__ __ /__ __ __
PLEASE ATTACH A COPY OF ALL HIV LABS (INCLUDING ANY GENOTYPE AND/OR PHENOTYPE).
VIII. CLINICAL STATUS
Clinical Record Reviewed:
Yes
No
Def. = definitive diagnosis
Enter Date Patient was diagnosed as: Asymptomatic: ____/____/____
Symptomatic (not AIDS): ____/____/____
Pres. = presumptive diagnosis
AIDS INDICATOR DISEASES
Def
Pres.
Initial Date (mo/day/yr)
AIDS INDICATOR DISEASES
Def
Pres.
Initial Date (mo/day/yr)
NA
NA
1) Candidiasis, bronchi, trachea, or lungs
14) Lymphoma, Burkitt’s (or equivalent term)
NA
2) Candidiasis, esophageal
15) Lymphoma, immunoblastic (or equivalent term)
NA
NA
3) Carcinoma, invasive cervical
16) Lymphoma, primary in brain
17) Mycobacterium avium complex or M. Kansasii
NA
4) Coccidioidomycosis, disseminated or extrapulmonary
disseminated or extrapulmonary
NA
5) Cryptococcosis, extrapulmonary
18) M. tuberculosis, pulmonary*
NA
6) Cryptosporidiosis, chronic intestinal (>1 month duration)
19) M. tuberculosis, disseminated or extrapulmonary*
20) Mycobacterium, of other species or unidentified
NA
7) Cytomegalovirus disease (other than in liver, spleen, or nodes)
species,disseminated or extrapulmonary
8) Cytomegalovirus retinitis (with loss of vision)
21) Pneumocystis carinii pneumonia
NA
9) HIV encephalopathy
22) Pneumonia, recurrent, in twelve (12) month period
10) Herpes simplex: chronic ulcer(s) (>1 month duration); or
NA
NA
bronchitis, pneumonitis or esophagitis
23) Progressive multifocal leukoencephalopathy
NA
NA
11) Histoplasmosis, disseminated or extra pulmonary
24) Salmonella septicemia, recurrent
NA
12) Isosporiasis, chronic intestinal (>1 month duration)
25) Toxoplasmosis of brain
NA
13) Kaposi’s sarcoma
26) Wasting syndrome due to HIV
*RVCT CASE NUMBER:
IX. TREATMENT/SERVICES REFERRALS
This patient is receiving or has been referred for:
Has this patient been informed of his/her HIV infection? …………………..……...
Yes
No
Yes
No
Unk.
 HIV-related medical services……………………………
This patient’s partners will be notified about their HIV exposure and counseled by:
DIS (Local Health Department
Physician/provider
Patient
ISDH Surveillance office needs to notify DIS
 Substance abuse treatment services…………………...
This patient has been enrolled at:
This patient received or is receiving:
This patient’s medical treatment is primarily reimbursed by:
Clinical Trial
Clinic
 Anti-retroviral
Yes
No
Unk.
NIH-sponsored
HRSA-sponsored
Medicaid
Private insurance/HMO
therapy
Yes
No
Unk.
Other
Other
No coverage
Other Public Funding
 PCP prophylaxis …
None
None
Clinical trial/government program
Unknown
Unknown
Unknown
X. FOR FEMALES ONLY
Is the patient currently pregnant?
Yes
No
Obstetrician/NP/Clinic/Family Doctor: ________________________________________________
Due Date: ______/______/______
Telephone Number: (
) _________________________
Is provider aware of her HIV status?
Yes
No
Has the patient been offered information regarding the use of HIV treatment medications during pregnancy?
Yes
No
Unk
If additional space is needed, please complete in the “Comments” section.
Name of Child(ren) (Born since original diagnosis): ____________________________________________________________________
Date(s) of Birth: __________/__________/___________
Hospital Name: _______________________________________________________________
City: _____________________________________
State: _____________________
Has the child been tested for HIV?
Yes
No
If yes, what was the result? _________
Was the child born before the mother’s last negative HIV test?
Yes
No
XI. HIV TESTING HISTORY
This section is to be completed using information obtained during patient interview. If a patient interview is not conducted, information may be
obtained via medical chart abstraction.
Date of interview (mo/day/yr): ____/____/____
Ever had a previous Positive HIV test?
Yes
No
Refused
Unknown
Date of first positive HIV test (mo/day/yr): ___/___/___
Ever had a negative HIV test?
Yes
No
Refused
Unknown
Date of last negative HIV test (mo/day/yr): ___/___/___
Number of negative HIV tests within twenty-four (24) months before first positive test: Number:_______
Refused
Don’t Know/Unknown
Ever taken any antiretrovirals (ARVs)?
Yes
No
Refused
Don’t Know/Unknown
If yes, name of the earliest ARV medication taken: ________________________________________________________________________
Dates ARVs taken – Date first began (mo/day/yr): ___/___/___
Dates ARVs taken – Date of last use (mo/day/yr): ___/___/___
As required by law : IC 35-42-1-7
XII. POST-TEST COUNSELING
Yes
No
Has the patient been told not to donate blood, plasma, organs, or other body tissue? ……………………………………………………………
Date (mo/day/yr) ______________
Has this patient been told of their duty to warn all sex and needle-sharing partners of their HIV status prior to engaging in this behavior?
Date (mo/day/yr) ______________
MUST COMPLETE:
Name of person that provided post-test counseling ____________________________________________________________________________
Telephone Number: (
) _____________________
XIII. COINFECTION/PARTNERS
COINFECTIONS
Yes
No
Unk.
Diagnosis Date
Acute
Chronic
Hepatitis B ……………………………………………………………………..
Hepatitis C ……………………………………………………………………..
Sexually Transmitted Disease (STD) ……………………………………….
Specify STD: ___________________________________
Sexually Transmitted Disease (STD) ……………………………………….
Specify STD: ___________________________________
Sexually Transmitted Disease (STD) ……………………………………….
Specify STD: ___________________________________
Does the patient have partners they would like to have ISDH assist them in notifying? (If additional space is needed, please complete in the “Comments” section.)
Name:
Address:
Telephone Number:
Email:
1. ____________________________________________________ ______________________________________________
______________________________
__________________________
2.____________________________________________________ ______________________________________________
______________________________
__________________________
3.____________________________________________________ ______________________________________________
______________________________
__________________________
If you have any questions when completing this form, please call : 1-800-376-2501
Please mail form to:
Reports for Residents of Marion County 
Reports for Residents of Elkhart, Jasper, 
Reports for Residents of All 
Residents should be sent to:  
Lake, Laporte, Newton, Porter and St. 
Remaining Counties should be sent 
Marion County Public Health 
Joseph Counties should be sent to:  
to:  
Department  
Lake County Health Department  
Office of Clinical Data and Research  
Attention: HIV Nurse Epidemiologist  
Attention: HIV/AIDS Surveillance Project 
Indiana State Department of Health  
2951 E. 38th Street  
Director  
2 N. Meridian Street, 6‐C 
rd
Indianapolis, IN 46205 
2900 W. 93
 Street 
Indianapolis, IN 46204 
Crown Point, Indiana 46307 
DO NOT FAX.
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