Form DCH-1355 "Michigan Adult HIV Confidential Case Report Form" - Michigan

What Is Form DCH-1355?

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

Form Details:

  • Released on September 1, 2019;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • 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 Form DCH-1355 by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DCH-1355 "Michigan Adult HIV Confidential Case Report Form" - Michigan

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Michigan Adult HIV Confidential Case Report Form
eHARS Entry Date:
STICKY #:26-
(Patients > 13 years of age)
PSWeb Entry Date:
I. SURVEILLANCE USE ONLY
DCH FORM #1355 Modified September 2019
Document ID
Soundex Code
Date Received at Surveillance
PSWeb Person ID#
State Number
MI00-
_______/________/_______
Document Source
Report Status
Report Medium
Surveillance Method
New
Update
A
F
P
R
II. PATIENT IDENTIFIER INFORMATION
Patient Legal Name Last:____________________________ First:_________________________ Middle:______________
Alias
Maiden Last:____________________________ First:_________________________ Middle:______________
Address Type:
Residential
Correctional
P.O.
Temporary
Homeless
Shelter
Foster Home
Current Address:__________________________________ City:_______________________ County:__________________
State:_______ Zip:___________ Phone:_________________ Mobile:____________________ SS#:____________________
Residence at Diagnosis
Residence at HIV diagnosis
Residence at Stage 3 (AIDS) diagnosis
(check all that apply):
Same as Current Address
Address:____________________________________________________________________
City:___________________________ County:_____________________ State/Country:_______________ Zip:__________
III. FACILITY OF DIAGNOSIS
Site of 1st Positive test for HIV Diagnosis
Site of Stage 3 (AIDS) Diagnosis
Facility Name:______________________________________________________________ Phone:_____________________
Address:____________________________________ City:_______________________ State:________ Zip:_____________
Provider Name Last:____________________ First:__________________ Provider Specialty:________________________
Facility Type:
Private Provider
Hosp Inpt
Hosp Out
ED
ID Clinic
LHD
CBO
CTR
Other
VI. CURRENT PROVIDER OF HIV CARE (
Same as Facility of Diagnosis)
Provider Name Last:____________________ First:___________________ Facility:________________________________
City:_______________________ State:______ Zip:________ Phone:______________ Med Rec No:___________________
V. FACILITY PROVIDING INFORMATION (
Same as Facility of Diagnosis) (
Same as Current Provider of Care)
Date Form Completed:________/_______/_________ Person Completing Form:___________________________________
Facility Completing Form:__________________________________________________ Phone:________________________
VI. DEMOGRAPHIC INFORMATION – COMPLETE ALL FIELDS
Case Status:
HIV Infection
Stage 3 (AIDS)
Do you suspect this is an acute (recent) infection?
Y
N
Sex at Birth
Gender Identity
Date of Birth
Country of Birth
Vital Status
Death Date
Marital Status
Male
Male
___/___/____
US
Unk
Alive
____/____/____
Single
Female
Female
Dead
Married
Trans
Female
Other (specify):
Unk
Divorced
to
Alias DOB
State/Terr of
Trans
Male
_____________
Widowed
to
___/___/____
Death:_________
Lives w/ Ptnr
Race:
Black (African American)
White
Asian
American Indian/Alaskan
Native Hawaiian/PI
Ethnicity:
Arab
Y
N
Unk
Latino/Hispanic
Y
N
Unk
VII. PATIENT HISTORY – COMPLETE ALL FIELDS
Before HIV Diagnosis, patient had:
Y
N
Unk
Before HIV Diagnosis, patient had:
Y
N
Unk
HETEROSEXUAL SEX WITH:
Sex with a male
Sex with a female
- An injection drug user (IDU)
- A bisexual male (females only)
Injected non-prescription drugs
Transplant/transfusion/clotting disorder*
- Person known to have HIV/AIDS
*and is claiming this as their source of HIV infection
High risk sex (detail in comment section)
Was patient perinatally infected?
VIII. TREATMENT/SERVICES REFERRALS (MI law requires providers to notify known partners or request help from LHD)
Patient Informed of HIV infection?
Y
N
Unk
Patient’s partners will be notified of exposure and counseled by:
Local Health Department
Clinical Care Provider
IX. WOMEN ONLY
Patient currently pregnant?
Y
N
Unk
IF YES, referred to OB?
Y
N
Unk
EDC (Due Date):____/____/____
Patient delivered live infants?
Y
N
Unk
IF YES, Most Recent Delivery Date:_____/______/_______
Delivery Hospital:__________________________ City:_________________ State:____ Child Name:___________________
Michigan Adult HIV Confidential Case Report Form
eHARS Entry Date:
STICKY #:26-
(Patients > 13 years of age)
PSWeb Entry Date:
I. SURVEILLANCE USE ONLY
DCH FORM #1355 Modified September 2019
Document ID
Soundex Code
Date Received at Surveillance
PSWeb Person ID#
State Number
MI00-
_______/________/_______
Document Source
Report Status
Report Medium
Surveillance Method
New
Update
A
F
P
R
II. PATIENT IDENTIFIER INFORMATION
Patient Legal Name Last:____________________________ First:_________________________ Middle:______________
Alias
Maiden Last:____________________________ First:_________________________ Middle:______________
Address Type:
Residential
Correctional
P.O.
Temporary
Homeless
Shelter
Foster Home
Current Address:__________________________________ City:_______________________ County:__________________
State:_______ Zip:___________ Phone:_________________ Mobile:____________________ SS#:____________________
Residence at Diagnosis
Residence at HIV diagnosis
Residence at Stage 3 (AIDS) diagnosis
(check all that apply):
Same as Current Address
Address:____________________________________________________________________
City:___________________________ County:_____________________ State/Country:_______________ Zip:__________
III. FACILITY OF DIAGNOSIS
Site of 1st Positive test for HIV Diagnosis
Site of Stage 3 (AIDS) Diagnosis
Facility Name:______________________________________________________________ Phone:_____________________
Address:____________________________________ City:_______________________ State:________ Zip:_____________
Provider Name Last:____________________ First:__________________ Provider Specialty:________________________
Facility Type:
Private Provider
Hosp Inpt
Hosp Out
ED
ID Clinic
LHD
CBO
CTR
Other
VI. CURRENT PROVIDER OF HIV CARE (
Same as Facility of Diagnosis)
Provider Name Last:____________________ First:___________________ Facility:________________________________
City:_______________________ State:______ Zip:________ Phone:______________ Med Rec No:___________________
V. FACILITY PROVIDING INFORMATION (
Same as Facility of Diagnosis) (
Same as Current Provider of Care)
Date Form Completed:________/_______/_________ Person Completing Form:___________________________________
Facility Completing Form:__________________________________________________ Phone:________________________
VI. DEMOGRAPHIC INFORMATION – COMPLETE ALL FIELDS
Case Status:
HIV Infection
Stage 3 (AIDS)
Do you suspect this is an acute (recent) infection?
Y
N
Sex at Birth
Gender Identity
Date of Birth
Country of Birth
Vital Status
Death Date
Marital Status
Male
Male
___/___/____
US
Unk
Alive
____/____/____
Single
Female
Female
Dead
Married
Trans
Female
Other (specify):
Unk
Divorced
to
Alias DOB
State/Terr of
Trans
Male
_____________
Widowed
to
___/___/____
Death:_________
Lives w/ Ptnr
Race:
Black (African American)
White
Asian
American Indian/Alaskan
Native Hawaiian/PI
Ethnicity:
Arab
Y
N
Unk
Latino/Hispanic
Y
N
Unk
VII. PATIENT HISTORY – COMPLETE ALL FIELDS
Before HIV Diagnosis, patient had:
Y
N
Unk
Before HIV Diagnosis, patient had:
Y
N
Unk
HETEROSEXUAL SEX WITH:
Sex with a male
Sex with a female
- An injection drug user (IDU)
- A bisexual male (females only)
Injected non-prescription drugs
Transplant/transfusion/clotting disorder*
- Person known to have HIV/AIDS
*and is claiming this as their source of HIV infection
High risk sex (detail in comment section)
Was patient perinatally infected?
VIII. TREATMENT/SERVICES REFERRALS (MI law requires providers to notify known partners or request help from LHD)
Patient Informed of HIV infection?
Y
N
Unk
Patient’s partners will be notified of exposure and counseled by:
Local Health Department
Clinical Care Provider
IX. WOMEN ONLY
Patient currently pregnant?
Y
N
Unk
IF YES, referred to OB?
Y
N
Unk
EDC (Due Date):____/____/____
Patient delivered live infants?
Y
N
Unk
IF YES, Most Recent Delivery Date:_____/______/_______
Delivery Hospital:__________________________ City:_________________ State:____ Child Name:___________________
X. DOCUMENTED LAB DATA
PATIENT NAME:___________________________________
*Questions concerning lab results? CALL US at 313 456-1571 or 517 335-8165*
*You may add copies of lab results to this form and may
*
HIV DIAGNOSTIC TESTS – please report all positive and subsequent negative tests
Type of Test
Collection
***At least 2 Antibody Tests must be indicated for an HIV
diagnosis***
Date
IA = ImmunoAssay
BioPlex
HIV-1/2 Ag/Ab Lab IA
N
(Discriminating & Differentiating Screen)
Screen
Determine
HIV-1/2 Ag/Ab Rapid IA
Y
Gen Discriminating Screen)
(4
th
rapid
HIV-1/2 Ag/Ab Lab IA
N
(4
Gen Screen)
th
HIV-1/2 Ab IA
Y N
(2
nd
or 3
rd
Gen Screen)
Geenius Ab
HIV1/HIV 2 Type Differentiating IA
Y
(Supplemental Test)
confirm
HIV-1 Western Blot
N
(Supplemental Test)
HIV-1 RNA/DNA Qualitative NAAT
N
OTHER:____________________________
Last Negative Test (prior to HIV diagnosis)
Y N
If HIV lab tests were NOT documented, is HIV diagnosis confirmed by a clinical care provider?
Yes
No
Unk
IF YES, please provide date of documentation by care provider:________/________/__________
HIV CARE TESTS
HIV-1 RNA Assay Quantitative Viral Load
Detectable
Undetectable
Copies/mL ________________
Collection Date________/__________/_________
Detectable
Undetectable
Copies/mL ________________
Collection Date________/__________/_________
CD4 Count at or closest to current diagnostic status
CD4 Count______________cells/ul
CD4 Percentage_____________% Collection Date_______/__________/__________
First CD4 Count <200 total lymphocytes
CD4 Count______________cells/ul
CD4 Percentage_____________% Collection Date_______/__________/__________
HIV Genotype
Sanger Sequence
Deep or NextGen Sequence
Collection Date________/__________/_________
XI. STAGE 3 (AIDS) OPPORTUNISTIC ILLNESSES (See Instructions for a list of opportunisitic illnesses)
Name of Opportunistic Illness:_______________________________ Illness Diagnosis Date_______/________/__________
XII. HIV TESTING AND TREATMENT HISTORY (TTH)
Date questions answered by patient: _______/_______/________
Main Source of TTH Info:
Medical Record Review
Patient Interview
Provider Report
Other
First Positive Test Reported by Patient:
Negative Tests Reported by Patient:
Ever have previous positive HIV test?
Y
N
Unk
Ever test negative?
Y
N
Unk
Date of 1
st
positive HIV test:______/______/_______
Date of most recent negative test: ______/______/_______
Anonymous 1st positive test?
Y
N
Unk
# of negative tests in 24 mo. before 1
st
positive test:______
Unk
History of ANY Antiretroviral Treatment (ARV) Use: CHECK HERE IF NO ARV USE EVER:
For HIV Tx?
ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
For PrEP?
ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
For PEP?
ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
For Preg mom? ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
For Hep B Tx?
ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
Currently using ARV?
Yes, Date of most recent use: _____/_____/______
No, Date of last use: _____/______/______
XIII. COMMENTS
_______________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
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