Form CDC50.42B "Pediatric Hiv Confidential Case Report Form"

What Is Form CDC50.42B?

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 November 1, 2019 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • 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 CDC50.42B 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.

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Download Form CDC50.42B "Pediatric Hiv Confidential Case Report Form"

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Patient Identification
(record all dates as mm/dd/yyyy)
*First Name
*Middle Name
*Last Name
Last Name Soundex
Alternate Name Type (example: Birth, Call Me)
*First Name
*Middle Name
*Last Name
*Current Address, Street
Address Date
Address Type
Residential
Bad address
Correctional facility
Foster home
Homeless
Military
Other
Postal
Shelter
Temporary
/
/
*Phone
City
County
State/Country
*ZIP Code
(
)
*Medical Record Number
*Other ID Type
*Number
Pediatric HIV Confidential Case Report Form
U.S. Department of Health
Centers for Disease Control
and Human Services
and Prevention (CDC)
(Patients aged <13 years 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. 11/30/2022
Date Received at Health Department
eHARS Document UID
State Number
/
/
Reporting Health Dept—City/County
City/County Number
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)
*Phone
Facility Name
(
)
*Street Address
City
County
State/Country
*ZIP Code
Facility
Inpatient:
Outpatient:
Other Facility:
Hospital
Private physician’s office
Pediatric clinic
Emergency room
Laboratory
Type
Other, specify
Pediatric HIV clinic
Other, specify
Unknown
Other, specify _____________________
Date Form Completed
*Person Completing Form
*Phone
/
/
(
)
Patient Demographics
(record all dates as mm/dd/yyyy)
Diagnostic Status at Report
3-Perinatal HIV exposure
Sex Assigned at Birth
Country of
US
Other/US dependency
4-Pediatric HIV
5-Pediatric AIDS
6-Pediatric seroreverter
Male
Female
Unknown
Birth
(please specify)
Date of Birth
/
/
Alias Date of Birth
/
/
Date of Death
/
/
State of Death
Vital Status
1-Alive
2-Dead
Date of Last Medical Evaluation
/
/
Date of Initial Evaluation for HIV
/
/
Expanded Ethnicity
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Unknown
Race
Expanded Race
American Indian/Alaska Native
Asian
Black/African American
(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 Event Type
Residence at HIV
Residence at stage
Residence at
Residence at
Check if SAME as
(check all that apply to address below)
diagnosis
3 (AIDS) diagnosis
perinatal exposure
pediatric seroreverter
current address
Address Type
Residential
Bad address
Correctional facility
Foster home
Homeless
Military
Other
Postal
Shelter
Temporary
*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.
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 50.42B
Rev. 11/2019
(Page 1 of 4)
—PEDIATRIC 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 (example: Birth, Call Me)
*First Name
*Middle Name
*Last Name
*Current Address, Street
Address Date
Address Type
Residential
Bad address
Correctional facility
Foster home
Homeless
Military
Other
Postal
Shelter
Temporary
/
/
*Phone
City
County
State/Country
*ZIP Code
(
)
*Medical Record Number
*Other ID Type
*Number
Pediatric HIV Confidential Case Report Form
U.S. Department of Health
Centers for Disease Control
and Human Services
and Prevention (CDC)
(Patients aged <13 years 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. 11/30/2022
Date Received at Health Department
eHARS Document UID
State Number
/
/
Reporting Health Dept—City/County
City/County Number
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)
*Phone
Facility Name
(
)
*Street Address
City
County
State/Country
*ZIP Code
Facility
Inpatient:
Outpatient:
Other Facility:
Hospital
Private physician’s office
Pediatric clinic
Emergency room
Laboratory
Type
Other, specify
Pediatric HIV clinic
Other, specify
Unknown
Other, specify _____________________
Date Form Completed
*Person Completing Form
*Phone
/
/
(
)
Patient Demographics
(record all dates as mm/dd/yyyy)
Diagnostic Status at Report
3-Perinatal HIV exposure
Sex Assigned at Birth
Country of
US
Other/US dependency
4-Pediatric HIV
5-Pediatric AIDS
6-Pediatric seroreverter
Male
Female
Unknown
Birth
(please specify)
Date of Birth
/
/
Alias Date of Birth
/
/
Date of Death
/
/
State of Death
Vital Status
1-Alive
2-Dead
Date of Last Medical Evaluation
/
/
Date of Initial Evaluation for HIV
/
/
Expanded Ethnicity
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Unknown
Race
Expanded Race
American Indian/Alaska Native
Asian
Black/African American
(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 Event Type
Residence at HIV
Residence at stage
Residence at
Residence at
Check if SAME as
(check all that apply to address below)
diagnosis
3 (AIDS) diagnosis
perinatal exposure
pediatric seroreverter
current address
Address Type
Residential
Bad address
Correctional facility
Foster home
Homeless
Military
Other
Postal
Shelter
Temporary
*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.
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 50.42B
Rev. 11/2019
(Page 1 of 4)
—PEDIATRIC 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)
Perinatal exposure
Check if SAME as facility providing information
Facility Name
*Phone (
)
*Street Address
City
County
State/Country
*ZIP Code
Facility Type
Inpatient:
Hospital
Outpatient:
Private physician’s office
Pediatric clinic
Other Facility
:
Emergency room
Laboratory
Pediatric HIV clinic
Other, specify
Unknown
Other, specify
Other, specify
*Provider Name
*Provider Phone (
)
Specialty
Patient History
(respond to all questions) (record all dates as mm/dd/yyyy)
Child’s biological mother’s HIV infection status (select one):
Refused HIV testing
Known to be uninfected after this child’s birth
Known HIV+ before pregnancy
Known HIV+ during pregnancy
Known HIV+ sometime before birth
Known HIV+ at delivery
Known HIV+ after child’s birth
HIV+, time of diagnosis unknown
HIV status unknown
Was the biological mother counseled about HIV testing during this pregnancy,
Date of mother’s first positive test to confirm infection
/
/
labor, or delivery?
Yes
No
Unknown
After 1977 and before the earliest known diagnosis of HIV infection, this child’s biological mother had:
Perinatally acquired HIV infection
Yes
No
Unknown
Injected nonprescription drugs
Yes
No
Unknown
Biological mother had 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
Biological mother had:
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
Before the diagnosis of HIV infection,
this child had:
Injected nonprescription drugs
Yes
No
Unknown
Received clotting factor for hemophilia/coagulation disorder
Yes
No
Unknown
Specify clotting factor:
Date received
/
/
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
Yes
No
Unknown
Sexual contact with male
Yes
No
Unknown
Sexual contact with female
Yes
No
Unknown
Other documented risk (please include detail in Comments)
Yes
No
Unknown
Clinical: Opportunistic Illnesses
(record all dates as mm/dd/yyyy)
Diagnosis
Dx Date
Diagnosis
Dx Date
Diagnosis
Dx Date
Bacterial infection, multiple or recurrent
HIV encephalopathy
Mycobacterium avium complex or M.
(including Salmonella septicemia)
kansasii, disseminated or extrapulmonary
1
Candidiasis, bronchi, trachea, or lungs
Herpes simplex: chronic ulcers (>1 mo. duration),
M. tuberculosis, pulmonary
bronchitis, pneumonitis, or esophagitis
Candidiasis, esophageal
Histoplasmosis, disseminated or extrapulmonary
M. tuberculosis, disseminated
1
or extrapulmonary
Carcinoma, invasive cervical
Isosporiasis, chronic intestinal (>1 mo. duration)
Mycobacterium, of other/unidentified
species, disseminated or extrapulmonary
Coccidioidomycosis, disseminated
Kaposi’s sarcoma
Pneumocystis pneumonia
or extrapulmonary
Cryptococcosis, extrapulmonary
Lymphoid interstitial pneumonia and/or
Pneumonia, recurrent in 12 mo. period
pulmonary lymphoid
Cryptosporidiosis, chronic intestinal
Lymphoma, Burkitt’s (or equivalent)
Progressive multifocal
(>1 mo. duration)
leukoencephalopathy
Cytomegalovirus disease
Lymphoma, immunoblastic (or equivalent)
Toxoplasmosis of brain, onset at >1 mo.
(other than in liver, spleen, or nodes)
of age
Cytomegalovirus retinitis (with loss
Lymphoma, primary in brain
Wasting syndrome due to HIV
of vision)
1
If a diagnosis date is entered for either tuberculosis diagnosis above, provide RVCT Case Number:
CDC 50.42B
Rev. 11/2019
(Page 2 of 4)
—PEDIATRIC 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
Positive
Negative
Indeterminate
Collection Date
/
/
Point-of-care rapid test
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
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 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
Overall interpretation:
Reactive
Nonreactive
Index value ______________
Not reportable due to high Ab level Index value
Analyte results: HIV-1 Ag:
Reactive
Nonreactive
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
Detectable
Undetectable Copies/mL _____________________________ Log _____________ Collection Date
/
/
Drug Resistance Tests (Genotypic)
TEST
HIV-1 Genotype (Unspecified)
Test brand name/Manufacturer _____________________________________ 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 were positive for HIV-1: Western blot, IFA, culture, viral load, qualitative NAAT (RNA or DNA), HIV-1/2 type-
differentiating immunoassay (supplemental test), stand-alone p24 antigen, or nucleotide sequence.
If laboratory tests were not documented,
HIV-infected
Yes
No
Unknown
Date of diagnosis
/
/
is patient confirmed by a physician as
Not HIV-infected
Date of diagnosis
Yes
No
Unknown
/
/
CDC 50.42B
Rev. 11/2019
(Page 3 of 4)
—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—
Birth History
(for Perinatal Cases only)
Birth history available?
Yes
No
Unknown
Residence at Birth
Check if SAME as current address
Address Type
Residential
Bad address
Correctional facility
Foster home
Homeless
Military
Other
Postal
Shelter
Temporary
*Street Address
City
County
State/Country
*ZIP Code
Facility of Birth
Check if SAME as facility providing information
Facility Name of Birth
*Phone
(if child was born at home, enter “home birth”)
(
)
Facility Type
Inpatient:
Outpatient:
Other Facility
Hospital
:
Emergency room
Corrections
Unknown
Other, specify
Other, specify
Other, specify
*Street Address
City
County
State/Country
*ZIP Code
Birth History
Birth Weight
lbs
oz
grams
Type
1-Single
2-Twin
3-More than two
9-Unknown
Delivery
1-Vaginal
2-Elective Cesarean
3-Nonelective Cesarean
4-Cesarean, unknown type
9-Unknown
Birth Defects
Yes
No
Unknown
If yes, specify types
Neonatal Status
1-Full-term
2-Premature
9-Unknown Neonatal Gestational Age in Weeks
(99 = Unknown, 00 = None)
Prenatal Care—Month of Pregnancy Prenatal Care Began
Prenatal Care—Total Number of Prenatal Care Visits
(99 = Unknown, 00 = None)
(99 = Unknown, 00 = None)
Did mother receive any antiretrovirals (ARVs) prior to this pregnancy?
If yes, specify all ARVs
Yes
No
Refused
Unknown
Date began __ __ / __ __ / __ __ __ __ Date of last use __ __ / __ __ / __ __ __ __
Did mother receive any ARVs during pregnancy?
If yes, specify all ARVs
Yes
No
Refused
Unknown
Date began __ __ / __ __ / __ __ __ __ Date of last use __ __ / __ __ / __ __ __ __
Did mother receive any ARVs during labor/delivery?
If yes, specify all ARVs
Yes
No
Refused
Unknown
Date began __ __ / __ __ / __ __ __ __ Date of last use __ __ / __ __ / __ __ __ __
Maternal Information
Maternal DOB __ __ / __ __ / __ __ __ __
Maternal Last Name Soundex
Maternal State ID Number
Maternal Country of Birth
*Other Maternal ID (specify type of ID and ID number)
Treatment/Services Referrals
(record all dates as mm/dd/yyyy)
This child ever taken any ARVs?
Yes
No
Unknown
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
/
/
Has this child ever taken PCP prophylaxis
Yes
No
Unknown Date began
/
Date of last use
/
/
/
Was this child breastfed?
Yes
No
Unknown
This child’s primary caretaker is
1-Biological parent
2-Other relative
3-Foster/Adoptive parent, relative
4-Foster/Adoptive parent, unrelated
7-Social service agency
8-Other (please specify in comments)
9-Unknown
Comments
*Local/Optional Fields
CDC 50.42B
Rev. 11/2019
(Page 4 of 4)
—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—
Page of 4