"Perinatal Hiv Exposure Case Report Form" - Rhode Island

Perinatal Hiv Exposure Case Report Form is a legal document that was released by the Rhode Island Department of Health - a government authority operating within Rhode Island.

Form Details:

  • Released on April 1, 2018;
  • The latest edition currently provided by the Rhode Island Department of Health;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Health.

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Download "Perinatal Hiv Exposure Case Report Form" - Rhode Island

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Perinatal HIV Exposure Case Report Form
Mail completed form to:
Rhode Island Department of Health, Center for HIV, Hepatitis, STDs, and TB Epidemiology
3 Capitol Hill, Room 106A, Providence, RI 02908 Tel: 401-222-2577
I. Reporting Information:
Date Reported to RIDOH
Facility Reporting
Person Reporting
Phone Number
II. Maternal Information:
Name (First, Middle, Last)
Date of Birth
Phone Number
State Number
Soundex
Street Address
City
County
State
ZIP Code
Country of Origin
Ethnicity
Race (check all that apply)
USA
Other / US Dependency
Not Hispanic or Latino
American Indian/Alaska Native
Asian
Black/African American
Please specify:
Hispanic or Latino
Native Hawaiian/Other Pacific Islander
White
Unknown
____________________________
Unknown
Other, specify: _____________________
Biological mother’s HIV infection status
Refused HIV testing
□ Known HIV+ before pregnancy
□ Known HIV+ during pregnancy
□ Known HIV+ sometime before birth
□ Known HIV+ at time of delivery □ Known HIV+ sometime after birth
□ Unknown
□ Male with documented HIV infection, risk unspecified
Maternal Risk
HETEROSEXUAL relations with any of the following:
□ Perinatally acquired HIV infection
□ Intravenous/injection drug user
□ Bisexual Male
□ Male with hemophilia/coagulation disorder
□ Injected non-prescription drugs
□ Transfusion recipient with documented HIV infection □ Transplant recipient with documented HIV infection
Maternal Diagnosis date
_______/________/__________
Date pregnancy began
_______/________/__________
Date prenatal care began
_______/________/__________
III. Pregnancy, Labor, and Delivery:
Were antiretroviral drugs prescribed for the mother during this pregnancy?
Yes (Complete Table)
No
Mom’s Last Viral Load Prior to
Delivery
Drug name
Date drug started
Gestational age (wks)
Date stopped
Date:
_____/______/______
/
/
/
/
___________
i.______________________
_____
______
_____
_____
______
_____
Result:
/
/
/
/
___________
ii.______________________
_____
______
_____
_____
______
_____
Mom’s Last CD4 Prior to
/
/
/
/
___________
iii.______________________
_____
______
_____
_____
______
_____
Delivery
Date: _____/______/______
?
□ Yes (Complete Table)
Result:
Did mother receive antiretroviral drugs during labor and delivery
No
Drug name
Drug
Date received
Time received
Type of administration
Refused
(mm/dd/yyyy)
Oral
IV
Unk
(circle)
AM or PM
i._______________________
____/ ____/_______
AM or PM
ii._______________________
____/_____/_______
AM or PM
iii._______________________
____/_____/_______
Type of Delivery
Delivery Method
Vaginal
Elective caesarean
Non-elective caesarean
Caesarean, unknown type
Neonatal Status
Full Term
Premature
Unknown
Neonatal Status Weeks: ___________
Single
Twin
>2
Facility at Birth
Birth Weight (lbs)
Birth Defects
IV. Infant Postpartum Care:
Infant’s Name (First, Middle, Last)
Sex
Date of Birth
Infant State Number
Female
Male
Ethnicity
Race (check all that apply)
American Indian/Alaska Native □ Asian □ Black/African American
Not Hispanic or Latino
Native Hawaiian/Other Pacific Islander
Hispanic or Latino
Unknown
□ White □ Unknown □ Other, specify: ___________________
Date of Initial HIV Testing
Type of Initial HIV Test
Results:
□ HIV -1 RNA/DNA NAAT (Quant)
/
/
______
_______
________
□ Other, specify: _________________
Division of Preparedness, Response, Infectious Disease, and Emergency Medical Services
April 2018
Perinatal HIV Exposure Case Report Form
Mail completed form to:
Rhode Island Department of Health, Center for HIV, Hepatitis, STDs, and TB Epidemiology
3 Capitol Hill, Room 106A, Providence, RI 02908 Tel: 401-222-2577
I. Reporting Information:
Date Reported to RIDOH
Facility Reporting
Person Reporting
Phone Number
II. Maternal Information:
Name (First, Middle, Last)
Date of Birth
Phone Number
State Number
Soundex
Street Address
City
County
State
ZIP Code
Country of Origin
Ethnicity
Race (check all that apply)
USA
Other / US Dependency
Not Hispanic or Latino
American Indian/Alaska Native
Asian
Black/African American
Please specify:
Hispanic or Latino
Native Hawaiian/Other Pacific Islander
White
Unknown
____________________________
Unknown
Other, specify: _____________________
Biological mother’s HIV infection status
Refused HIV testing
□ Known HIV+ before pregnancy
□ Known HIV+ during pregnancy
□ Known HIV+ sometime before birth
□ Known HIV+ at time of delivery □ Known HIV+ sometime after birth
□ Unknown
□ Male with documented HIV infection, risk unspecified
Maternal Risk
HETEROSEXUAL relations with any of the following:
□ Perinatally acquired HIV infection
□ Intravenous/injection drug user
□ Bisexual Male
□ Male with hemophilia/coagulation disorder
□ Injected non-prescription drugs
□ Transfusion recipient with documented HIV infection □ Transplant recipient with documented HIV infection
Maternal Diagnosis date
_______/________/__________
Date pregnancy began
_______/________/__________
Date prenatal care began
_______/________/__________
III. Pregnancy, Labor, and Delivery:
Were antiretroviral drugs prescribed for the mother during this pregnancy?
Yes (Complete Table)
No
Mom’s Last Viral Load Prior to
Delivery
Drug name
Date drug started
Gestational age (wks)
Date stopped
Date:
_____/______/______
/
/
/
/
___________
i.______________________
_____
______
_____
_____
______
_____
Result:
/
/
/
/
___________
ii.______________________
_____
______
_____
_____
______
_____
Mom’s Last CD4 Prior to
/
/
/
/
___________
iii.______________________
_____
______
_____
_____
______
_____
Delivery
Date: _____/______/______
?
□ Yes (Complete Table)
Result:
Did mother receive antiretroviral drugs during labor and delivery
No
Drug name
Drug
Date received
Time received
Type of administration
Refused
(mm/dd/yyyy)
Oral
IV
Unk
(circle)
AM or PM
i._______________________
____/ ____/_______
AM or PM
ii._______________________
____/_____/_______
AM or PM
iii._______________________
____/_____/_______
Type of Delivery
Delivery Method
Vaginal
Elective caesarean
Non-elective caesarean
Caesarean, unknown type
Neonatal Status
Full Term
Premature
Unknown
Neonatal Status Weeks: ___________
Single
Twin
>2
Facility at Birth
Birth Weight (lbs)
Birth Defects
IV. Infant Postpartum Care:
Infant’s Name (First, Middle, Last)
Sex
Date of Birth
Infant State Number
Female
Male
Ethnicity
Race (check all that apply)
American Indian/Alaska Native □ Asian □ Black/African American
Not Hispanic or Latino
Native Hawaiian/Other Pacific Islander
Hispanic or Latino
Unknown
□ White □ Unknown □ Other, specify: ___________________
Date of Initial HIV Testing
Type of Initial HIV Test
Results:
□ HIV -1 RNA/DNA NAAT (Quant)
/
/
______
_______
________
□ Other, specify: _________________
Division of Preparedness, Response, Infectious Disease, and Emergency Medical Services
April 2018
IV. Infant Postpartum Care (continued)
Were antiretroviral drugs prescribed for the infant after delivery?
Yes (Complete Table)
No
Drug name
Drug refused
Date drug started
Drug stopped
Date stopped
/
/
/
/
i.___________________________
_____
______
_____
_____
______
_____
/
/
/
/
ii.__________________________
_____
______
_____
_____
______
_____
/
/
/
/
iii.__________________________
_____
______
_____
_____
______
_____
V. Provider Information
Infant’s General Pediatrician
Infant’s HIV Specialty Pediatrician
Infant’s Case Manager (Person & Organization)
Infant’s Primary Caregiver
Phone Number
Relationship
Mother
Other, specify: ________________________________
General comments
VI. Infant Follow Up Test Information
(RIDOH use only)
HIV Test Date
HIV Test
HIV Test Result
HIV Test Date
HIV Test Type
HIV Test Result
Type
□ HIV-negative
□ HIV-positive
□ Unknown
Infant Final Disposition:
Date Closed:
RIDOH Staff:
Division of Preparedness, Response, Infectious Disease, and Emergency Medical Services
April 2018
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