"Adult Hiv Confidential Case Report Form" - Rhode Island

Adult Hiv Confidential Case Report Form is a legal document that was released by the Rhode Island Department of Environmental Management - a government authority operating within Rhode Island.

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Adult HIV Confidential Case Report Form
(Patients
13 years of age at time of diagnosis)
Mail completed form to:
Rhode Island Department of Health, Center for HIV, Hepatitis, STDs, and TB Epidemiology
Room 106A, 3 Capitol Hill, Providence, RI 02908 Tel: 401-222-2577
This section: Rhode Island Department of Health (RIDOH) use only
Surveillance Method
Active
Passive
Follow up
Reabstraction
Unknown
Date Received at RIDOH _______/_______/_____
Did this report initiate a new case investigation?
Yes
No
Unknown
State Number
Report Medium
1-Field Visit
2-Mailed
3-Faxed
4-Phone
5-Electronic Transfer
6-CD/Disk
Last Name Soundex
Patient Information
Record all dates as mm/dd/yyyy.
Patient Name
(First, Middle, Last)
Alternate Name Type
(First, Middle, Last [ex. Alias, Married])
Current Street Address
Phone (
)
Address Type
Residential
Bad Address
Foster Home
Correctional Facility
Homeless
Postal
Shelter
Temporary
City
County
State/Country
Zip Code
Medical Record Number
Other ID Type (Social Security #, or other) Number
Facility Providing Information
Facility name
Phone (
)
Street Address
City
County
State/Country
Zip Code
Facility Type
Inpatient:
Hospital
Other _____________ Outpatient:
Private physician’s office
Adult HIV Clinic
Other, specify ___________
Screening Diagnostic Referral Agency:
CTS
STD Clinic
Other, specify __________ Other Facility:
Emergency Room
Laboratory
Corrections
Unknown
Other, specify ____________
Person Completing Form
Date Form
Phone
Completed ______/_______/_______
(
)
Patient Demographics
Sex assigned at birth
Male
Female
Unknown Country of birth
US
Other / US Dependency Please specify: __________________
Date of birth _______/_______/________
Alias date of birth ______/_______/_______
Vital Status
Date of death ______/_______/_______
Alive
Dead
State of death ________________________
Current gender identity
M
ale
Female
Transgender male-to-female (MTF)
Transgender female-to-male (FTM)
Unknown
Additional gender identity, specify
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Race (check all that apply)
American Indian/Alaska Native
Asian
Black/African American
Expanded ethnicity:
Unknown
Expanded race:
Native Hawaiian/Pacific Islander
White/Caucasian
Unknown
____________________________
__________________________
Residence At Diagnosis
Add additional addresses in comments, page 4.
Address type (check all that apply)
Check if SAME as current address
Residence at HIV diagnosis
Residence at Stage 3 (AIDS) diagnosis
Street Address
City
County
State/Country
Zip Code
Division of Preparedness Response,
Infectious Diseases & EMS
1
As of 05/2018
Adult HIV Confidential Case Report Form
(Patients
13 years of age at time of diagnosis)
Mail completed form to:
Rhode Island Department of Health, Center for HIV, Hepatitis, STDs, and TB Epidemiology
Room 106A, 3 Capitol Hill, Providence, RI 02908 Tel: 401-222-2577
This section: Rhode Island Department of Health (RIDOH) use only
Surveillance Method
Active
Passive
Follow up
Reabstraction
Unknown
Date Received at RIDOH _______/_______/_____
Did this report initiate a new case investigation?
Yes
No
Unknown
State Number
Report Medium
1-Field Visit
2-Mailed
3-Faxed
4-Phone
5-Electronic Transfer
6-CD/Disk
Last Name Soundex
Patient Information
Record all dates as mm/dd/yyyy.
Patient Name
(First, Middle, Last)
Alternate Name Type
(First, Middle, Last [ex. Alias, Married])
Current Street Address
Phone (
)
Address Type
Residential
Bad Address
Foster Home
Correctional Facility
Homeless
Postal
Shelter
Temporary
City
County
State/Country
Zip Code
Medical Record Number
Other ID Type (Social Security #, or other) Number
Facility Providing Information
Facility name
Phone (
)
Street Address
City
County
State/Country
Zip Code
Facility Type
Inpatient:
Hospital
Other _____________ Outpatient:
Private physician’s office
Adult HIV Clinic
Other, specify ___________
Screening Diagnostic Referral Agency:
CTS
STD Clinic
Other, specify __________ Other Facility:
Emergency Room
Laboratory
Corrections
Unknown
Other, specify ____________
Person Completing Form
Date Form
Phone
Completed ______/_______/_______
(
)
Patient Demographics
Sex assigned at birth
Male
Female
Unknown Country of birth
US
Other / US Dependency Please specify: __________________
Date of birth _______/_______/________
Alias date of birth ______/_______/_______
Vital Status
Date of death ______/_______/_______
Alive
Dead
State of death ________________________
Current gender identity
M
ale
Female
Transgender male-to-female (MTF)
Transgender female-to-male (FTM)
Unknown
Additional gender identity, specify
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Race (check all that apply)
American Indian/Alaska Native
Asian
Black/African American
Expanded ethnicity:
Unknown
Expanded race:
Native Hawaiian/Pacific Islander
White/Caucasian
Unknown
____________________________
__________________________
Residence At Diagnosis
Add additional addresses in comments, page 4.
Address type (check all that apply)
Check if SAME as current address
Residence at HIV diagnosis
Residence at Stage 3 (AIDS) diagnosis
Street Address
City
County
State/Country
Zip Code
Division of Preparedness Response,
Infectious Diseases & EMS
1
As of 05/2018
Facility of Diagnosis
Add additional facilities in Comments, page 4.
□ HIV
□ Stage 3 (AIDS)
□ Check if SAME as Facility Providing Information, Page 1
Diagnosis type
Facility Name
Phone (
)
Street Address
City
County
State/Country
Zip Code
Outpatient:
Other Facility:
Emergency Room
Facility type:
Inpatient:
Screening Diagnostic Referral
Private physician’s office
Laboratory
Corrections
Hospital
Agency:
Other
Adult HIV Clinic
CTS
STD Clinic
Unknown
Other, specify _____________
Other, specify
Other, specify
Provider phone (
)
Provider name
Specialty
Patient History
Respond to all questions.
Pediatric risk: If applicable, check and note in Comments, page 4.
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
□ Yes □ No □ Unknown
Sex with male
□ Yes □ No □ Unknown
Sex with female
□ Yes □ No □ Unknown
Injected non-prescription drugs
□ Yes □ No □ Unknown
Received clotting factor for hemophilia/
Specify clotting factor:
coagulation disorder
Date received (mm/dd/yyyy):
/
/
HETEROSEXUAL relations with any of the following:
□ Yes □ No □ Unknown
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, page 4.
First date received
/
/
Last date received
/
/
□ Yes □ No □ Unknown
Received transplant of tissue/organs or artificial insemination
□ Yes □ No □ Unknown
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:
□ Yes □ No □ Unknown
Other documented risk (Please include details in Comments, page 4.)
Clinical (Acute HIV Infection and Opportunistic Illnesses)
□ Yes □ No □ Unk
Suspect acute HIV infection? 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.
□ Yes □ No □ Unk
Clinical signs/symptoms consistent with acute retroviral syndrome (e.g., fever,
malaise/fatigue, myalgia, pharyngitis, rash, lymphadenopathy)? Date of sign/symptom onset _______/ _______ / _______
□ Yes □ No □ Unk
Other evidence suggestive of acute HIV infection?
Date of evidence
If YES, please describe:
_______/ _______ / _______
Opportunistic Illnesses
Diagnosis
Diagnosis
Diagnosis
Date
Date
Date
1
M. tuberculosis, pulmonary
Candidiasis, bronchi, trachea, or lungs
Herpes simplex: chronic ulcers (>1 mo.
duration), bronchitis, pneumonitis, or esophagitis
Candidiasis, esophageal
Histoplasmosis, disseminated or
M. tuberculosis, disseminated or
extrapulmonary
1
extrapulmonary
Carcinoma, invasive cervical
Isosporiasis, chronic intestinal
Mycobacterium, of other/unidentified
species, disseminated or extrapulmonary
(>1 mo. duration)
Coccidiodomycosis,
Kaposi’s sarcoma
Pneumocystis pneumonia
disseminated or 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)
Mycobacterium avium complex or M. kansasii,
Cytomegalovirus retinitis (with loss of
Toxoplasmosis of brain, onset at >1 mo.
vision)
disseminated or extrapulmonary
of age
HIV encephalopathy
Wasting syndrome due to HIV
1
If TB selected above, indicate RVCT Case Number:
Division of Preparedness Response,
Infectious Diseases & EMS
2
As of 05/2018
Laboratory Data
Record additional tests in Comments, page 4.
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 _____________________________________________
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
Result
Positive
Negative
Indeterminate
Collection Date _____/_______/_________
Point-of-care rapid test
HIV Immunoassays (Differentiating)
Role of test in diagnostic algorithm
HIV-1/2 type-differentiating immunoassay
(differentiates between HIV-1 Ab and HIV-2 Ab)
Screening/initial test
Confirmatory/supplemental test
Test brand name/Manufacturer____________________________________ Lab name _____________________________________________
1
Result
Overall interpretation:
HIV-1 positive
HIV-2 positive
HIV positive, untypable
HIV-2 positive with HIV-1 cross-reactivity
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 analyte results when available.
HIV-1/2 Ag/Ab differentiating immunoassay (differentiates between HIV Ag and HIV Ab)
Test brand name/Manufacturer ____________________________________ Lab 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 _____________________________________________
2
Result
Overall interpretation:
Reactive
Nonreactive
Index value ____________________________________
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 _____________________________________________
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 _____________________________________________
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 _____________________________________________
Result
Detectable
Undetectable Copies/mL_________________ Log___________ Collection Date _____/_______/_________
Drug Resistance Tests (Genotypic)
TEST
HIV-1 Genotype (Unspecified)
Test brand name/Manufacturer ______________________________________
Lab 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 _____________________________________________
First CD4 result <200 cells/µL or <14%: CD4 count____________ cells/µL CD4 percentage________% Collection Date _____/_______/_________
Test brand name/Manufacturer____________________________________ Lab name _____________________________________________
Other CD4 result: CD4 count_________________ cells/µL CD4 percentage_______________% Collection Date _____/_______/_________
Test brand name/Manufacturer____________________________________ Lab 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 _____/_______/_________
Type of test:
Provider
Date of last documented negative HIV test _____/_______/_________
(before HIV diagnosis date)
Division of Preparedness Response,
Infectious Diseases & EMS
3
As of 05/2018
Treatment/Services Referrals
Has this patient been informed of his/her HIV
This patient’s partners will be notified about their HIV exposure and counseled by:
infection?
Yes
No
Unknown
1-Health Dept
2-Physician/Provider
3-Patient
9-Unknown
For female patients
This patient is receiving or has been referred for
Is this patient currently pregnant?
Has this patient delivered live-
gynecological or obstetrical services:
born infants?
Yes
No
Unknown
Yes
No
Unknown
If YES, due date:
/
/
Yes
No
Unknown
If YES, provider name:
For children of patient: R
ecord most recent birth in the fields below. Record additional or multiple births in Comments below.
Child’s Name
Child’s Date of Birth
/
/
Child’s Last Name Soundex
Child’s State Number
Facility of Birth (if child was born at home, enter “home birth” for hospital name)
Phone (
)
Street Address
City
County
State/Country
Zip Code
Antiretroviral Use History
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
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 known test
type, enter in Lab Data section)
_____/_______/_____
Number of negative HIV tests within the 24 months before the first positive test_____________
Unknown
Comments
Optional Fields
This patient is also diagnosed with:
Syphilis
Yes
No
Unknown
Date_____/_______/_______
Hepatitis B
Yes
No
Unknown
Date_____/_______/_______
Hepatitis C
Yes
No
Unknown
Date_____/_______/_______
~ This form was adapted from CDC Form 50.42A Rev.02/2018 ~
Division of Preparedness Response,
Infectious Diseases & EMS
4
As of 05/2018
Page of 4