Form CDPH 8641A Adult Hiv/Aids Case Report Form - California

Form CDPH8641A is a California Department of Public Health form also known as the "Adult Hiv/aids Case Report Form". The latest edition of the form was released in May 1, 2013 and is available for digital filing.

Download a PDF version of the Form CDPH8641A down below or find it on California Department of Public Health Forms website.

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State of California - Health and Human Services Agency
California Department of Public Health - Office of AIDS
ADULT HIV/AIDS CASE REPORT FORM
(Patients ≥ 13 Years of Age at Time of Diagnosis)
I. Health Department Use Only
(See Appendix 1.0 for Further Details) (Record All Dates as mm/dd/yyyy)
Shaded Fields are Required. All Others are Optional.
Name of Person Completing Form:
Person’s Phone Number:
STATENO:
CITYNO:
(
)
Date Form Completed
Reporting Health Department - City/County:
Document Source:
:
_____/_____/________
Report Status:
Physician’s Name:
Physician’s Phone Number:
Hospital/Facility Name:
1- New
2- Update
(
)
Did this report initiate a new case investigation?
Surveillance Method:
Report Medium:
Active
Passive
1- Field Visit
2- Mailed
Yes
No
Unknown
Follow Up
Reabstraction
Unknown
3- Phone
4- Electronic Transfer
5- CD/Disk
II. Patient Identification
Patient Last Name:
Middle Name:
First Name:
Last Name:
Middle Name:
First Name:
Alternate Name Type
(e.g. Alias, Married, etc.):
Address Type:
Residential
Bad Address
Correctional Facility
Foster Home
Homeless
Postal
Shelter
Temporary
Current Street Address:
City:
County:
State/Country:
ZIP Code:
Phone Number:
Social Security Number:
Other ID Type #1:
(
)
Other ID Type #1 Number:
Other ID Type #2:
Other ID Type #2 Number:
III. Patient Demographics
(See Appendix 2.0 for Further Details) (Record All Dates as mm/dd/yyyy)
Sex Assigned at Birth:
Country of Birth:
Date of Birth
:
Male
Female
Unknown
U.S.
Other/U.S. Dependency (please specify):
_____/_____/________
Alias Date of Birth
Vital Status:
Date of Death
State of Death:
Status:
:
:
1- Alive
2- Dead
HIV
AIDS
_____/_____/________
_____/_____/________
Current Gender Identity:
Race:
Male
Female
Transgender: Male-to-Female (MTF)
White
Black/African American
Transgender: Female-to-Male (FTM)
Unknown
American Indian/Alaskan Native
Other Gender Identity (specify):
Asian
Pacific Islander
Ethnicity:
Expanded Ethnicity:
Hispanic/Latino
Chinese
Vietnamese
Hawaiian
Japanese
Asian Indian
Guamanian
Not Hispanic/Latino
Unknown
Filipino
Laotian
Samoan
Expanded Race:
Korean
Cambodian
Other (specify):
IV. Residence at Diagnosis
(See Appendix 3.0 for Further Details - Add Additional Addresses in Comments and Local/Optional Fields Section) (Required as Appropriate Based on Status)
Address Type
Residence at HIV Diagnosis
Residence at AIDS Diagnosis
Check if SAME as Current Address
(check all that apply):
Street Address:
City:
County:
State/Country:
ZIP Code:
Address of Residence
at HIV Diagnosis
County:
State/Country:
ZIP Code:
Street Address:
City:
Address of Residence
at AIDS Diagnosis
CDPH 8641A (05/13)
Page 1 of 4
State of California - Health and Human Services Agency
California Department of Public Health - Office of AIDS
ADULT HIV/AIDS CASE REPORT FORM
(Patients ≥ 13 Years of Age at Time of Diagnosis)
I. Health Department Use Only
(See Appendix 1.0 for Further Details) (Record All Dates as mm/dd/yyyy)
Shaded Fields are Required. All Others are Optional.
Name of Person Completing Form:
Person’s Phone Number:
STATENO:
CITYNO:
(
)
Date Form Completed
Reporting Health Department - City/County:
Document Source:
:
_____/_____/________
Report Status:
Physician’s Name:
Physician’s Phone Number:
Hospital/Facility Name:
1- New
2- Update
(
)
Did this report initiate a new case investigation?
Surveillance Method:
Report Medium:
Active
Passive
1- Field Visit
2- Mailed
Yes
No
Unknown
Follow Up
Reabstraction
Unknown
3- Phone
4- Electronic Transfer
5- CD/Disk
II. Patient Identification
Patient Last Name:
Middle Name:
First Name:
Last Name:
Middle Name:
First Name:
Alternate Name Type
(e.g. Alias, Married, etc.):
Address Type:
Residential
Bad Address
Correctional Facility
Foster Home
Homeless
Postal
Shelter
Temporary
Current Street Address:
City:
County:
State/Country:
ZIP Code:
Phone Number:
Social Security Number:
Other ID Type #1:
(
)
Other ID Type #1 Number:
Other ID Type #2:
Other ID Type #2 Number:
III. Patient Demographics
(See Appendix 2.0 for Further Details) (Record All Dates as mm/dd/yyyy)
Sex Assigned at Birth:
Country of Birth:
Date of Birth
:
Male
Female
Unknown
U.S.
Other/U.S. Dependency (please specify):
_____/_____/________
Alias Date of Birth
Vital Status:
Date of Death
State of Death:
Status:
:
:
1- Alive
2- Dead
HIV
AIDS
_____/_____/________
_____/_____/________
Current Gender Identity:
Race:
Male
Female
Transgender: Male-to-Female (MTF)
White
Black/African American
Transgender: Female-to-Male (FTM)
Unknown
American Indian/Alaskan Native
Other Gender Identity (specify):
Asian
Pacific Islander
Ethnicity:
Expanded Ethnicity:
Hispanic/Latino
Chinese
Vietnamese
Hawaiian
Japanese
Asian Indian
Guamanian
Not Hispanic/Latino
Unknown
Filipino
Laotian
Samoan
Expanded Race:
Korean
Cambodian
Other (specify):
IV. Residence at Diagnosis
(See Appendix 3.0 for Further Details - Add Additional Addresses in Comments and Local/Optional Fields Section) (Required as Appropriate Based on Status)
Address Type
Residence at HIV Diagnosis
Residence at AIDS Diagnosis
Check if SAME as Current Address
(check all that apply):
Street Address:
City:
County:
State/Country:
ZIP Code:
Address of Residence
at HIV Diagnosis
County:
State/Country:
ZIP Code:
Street Address:
City:
Address of Residence
at AIDS Diagnosis
CDPH 8641A (05/13)
Page 1 of 4
V. Facility at Diagnosis
STATENO:
(See Appendix 4.0 for Further Details - Add Additional Facilities in Comments and Local/Optional Fields Section)
Diagnosis Type
(check all that apply to facility):
HIV Diagnosis
AIDS Diagnosis
Check if SAME as Facility Providing Information
City:
Facility Name:
Phone Number:
Street Address:
(
)
County:
State/Country:
ZIP Code:
Provider Name:
Inpatient:
Hospital
Other (specify):
Outpatient:
Private Physician
Adult HIV Clinic
Other (specify):
Facility Type:
Screening, Diagnostic, Referral Agency:
CTS
STD Clinic
Other (specify):
Other Facility:
Emergency Room
Laboratory
Corrections
Unknown
Other (specify):
VI. Patient History
(See Appendix 5.0 for Further Details - Respond to All Questions)
Pediatric Risk (Please Enter in Comments and Local/Optional Fields Section)
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
Sex with a male:
Sex with a female:
Injected non-prescription drugs:
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
HETEROSEXUAL relations with any of the following:
Has the patient:
Contact with intravenous/injection drug user (IDU):
Yes
No
Unknown
Received clotting factor for hemophilia/coagulation
disorder:
Yes
No
Unknown
Contact with a bisexual male:
Yes
No
Unknown
Received transfusion of blood/blood components
Contact with a person with AIDS or documented HIV
(non-clotting):
Yes
No
Unknown
infection, risk not specified:
Yes
No
Unknown
Other documented risk:
Contact with transplant recipient with documented HIV:
Yes
No
Unknown
(if yes, specify):
Yes
No
Unknown
Contact with transfusion recipient with documented HIV:
Yes
No
Unknown
VII. Laboratory Data
(Record All Dates as mm/dd/yyyy) (See Instructions for Details)
HIV Antibody Tests (Non-Type Differentiating) [HIV-1 vs. HIV-2]
TEST 1:
HIV-1 EIA
HIV-1/2 EIA
HIV-1/2 Ag/Ab
HIV-1 WB
HIV-1 IFA
HIV-2 EIA
HIV-2 WB
Other (specify test):
RESULT:
Positive/Reactive
Negative/Nonreactive
Indeterminate
RAPID TEST
Collection Date
(check if rapid):
:
_____/_____/________
Manufacturer:
TEST 2:
HIV-1 EIA
HIV-1/2 EIA
HIV-1/2 Ag/Ab
HIV-1 WB
HIV-1 IFA
HIV-2 EIA
HIV-2 WB
Other (specify test):
RESULT:
Positive/Reactive
Negative/Nonreactive
Indeterminate
RAPID TEST
Collection Date
(check if rapid):
:
_____/_____/________
Manufacturer:
TEST 3:
HIV-1 EIA
HIV-1/2 EIA
HIV-1/2 Ag/Ab
HIV-1 WB
HIV-1 IFA
HIV-2 EIA
HIV-2 WB
Other (specify test):
RESULT:
Positive/Reactive
Negative/Nonreactive
Indeterminate
RAPID TEST
Collection Date
(check if rapid):
:
_____/_____/________
Manufacturer:
HIV Antibody Tests (Type Differentiating) [HIV-1 vs. HIV-2]
TEST:
HIV-1/2 Differentiating (e.g. Multispot)
RESULT:
Collection Date
HIV-1
HIV-2
Both (undifferentiated)
Neither (negative)
:
_____/_____/________
CDPH 8641A (05/13)
Page 2 of 4
VII. Laboratory Data (continued)
STATENO:
(Record All Dates as mm/dd/yyyy)
HIV Detection Tests (Qualitative)
TEST 1:
HIV-1 RNA/DNA NAAT (Qual)
HIV-1 P24 Antigen
HIV-1 Culture
HIV-2 RNA/DNA NAAT (Qual)
HIV-2 Culture
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
RESULT:
Positive/Reactive
Negative/Nonreactive
Indeterminate
Collection Date
:
_____/_____/________
HIV Detection Tests (Quantitative Viral Load)
Note: Include earliest test after diagnosis
HIV-1 RNA/DNA NAAT (Quantitative Viral Load)
RT-PCR
bDNA
Other (specify test):
TEST 1:
RESULT:
Detectable
Undetectable
Copies/mL:
Log:
Collection Date
:
_____/_____/________
TEST 2:
HIV-1 RNA/DNA NAAT (Quantitative Viral Load)
RT-PCR
bDNA
Other (specify test):
RESULT:
Detectable
Undetectable
Copies/mL:
Log:
Collection Date
:
_____/_____/________
Immunologic Tests (CD4 Count and Percentage)
CD4 at or closest to current diagnosis status: CD4 count:
CD4 percentage:
Collection Date
cells/µL
%
:
_____/_____/________
First CD4 result <200 cells/µL or <14%:
CD4 count:
CD4 percentage:
Collection Date
cells/µL
%
:
_____/_____/________
Other CD4 result <200 cells/µL or <14%:
CD4 count:
CD4 percentage:
Collection Date
cells/µL
%
:
_____/_____/________
Documentation of Tests
(Complete 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?
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?
Yes
No
Unknown
If yes, provide date of documentation by physician: _____/_____/________
VIII. Clinical
(Check Boxes Where Applicable) (Record All Dates as mm/dd/yyyy)
Date
Date
Candidiasis, esophageal
Kaposi’s sarcoma
Cryptococcosis, extrapulmonary
Pneumocystis carinii pneumonia
Wasting syndrome due to HIV
Cytomegalovirus disease
(other than in liver, spleen or nodes)
Herpes simplex: chronic ulcer(s) (>1 mo. duration),
Other (specify):
bronchitis, pneumonitis or esophagitis
IX. Treatment/Services Referrals
(Record All Dates as mm/dd/yyyy)
Has This Patient Been Informed of His/Her HIV Infection?
Yes
No
Unknown
Patient’s Medical Treatment is Primarily Reimbursed by:
1- Medicaid
2- Private Insurance/HMO
3- No Coverage
4- Other Public Funding
9- Unknown
For Female Patient:
Is This Patient Currently Pregnant?
Yes
No
Unknown
Has This Patient Delivered Live-Born Infants?
Yes
No
Unknown
CDPH 8641A (05/13)
Page 3 of 4
IX. Treatment/Services Referrals (continued)
STATENO:
(Record All Dates as mm/dd/yyyy)
For Children of Patient:
(Record Most Recent Birth Below; Record Additional or Multiple Births in Comments and Local/Optional Fields Section)
Child’s Name:
Child’s Soundex:
Child’s Date of Birth
:
______/______/________
Child’s Coded ID:
Child’s STATENO:
Hospital of Birth:
(If Child Was Born at Home, Enter “Home Birth” for Hospital Name)
Hospital Name:
Phone Number:
(
)
Street Address:
City:
County:
State/Country:
ZIP Code:
X. HIV Testing and Antiretroviral Use History (TTH)
(Record All Dates as mm/dd/yyyy) (Required Sections for New Case Report Only)
Main Source of Testing and Treatment History Information
Date Patient Reported Information
(select one):
Patient Interview
Medical Record Review
:
Provider Report
NHM&E/PEMS
Other (specify):
_____/_____/________
Ever Had a Positive HIV Test?
Date of First Positive HIV Test
Ever Had a Negative HIV Test?
Date of Last Negative HIV Test
:
: (If date is from a lab test
Yes
No
Refused
Yes
No
Refused
with test type, enter in
_____/_____/________
_____/_____/________
Don’t Know/Unknown
Don’t Know/Unknown
Laboratory Data Section.)
Number of Negative HIV Tests Within 24 Months Before First Positive Test
(#):
Refused
Don’t Know/Unknown
Ever Taken Any Antiretrovirals (ARVs)?
If Yes, What ARV Medications?
Yes
No
Refused
Don’t Know/Unknown
Date ARVs First Taken
Date ARVs Last Taken
:
(mm/dd/yyyy):
_____/_____/________
_____/_____/________
XI. Duplicate Review
Status
Same As
Different Than
Pending
State Name:
STATENO:
(check one):
XII. Comments and Local/Optional Fields
LOCAL HEALTH DEPARTMENTS:
SUBMIT COMPLETED FORM TO THE OFFICE OF AIDS PER YOUR CONTRACT’S SCOPE OF WORK, EXHIBIT A, PART D, OBJECTIVE 2.
PROVIDERS:
SUBMIT COMPLETED FORM MARKED “CONFIDENTIAL” TO THE HIV/AIDS SURVEILLANCE PROGRAM AT YOUR LOCAL HEALTH DEPARTMENT.
Local Health Department HIV/AIDS contact list is available at: www.cdph.ca.gov/programs/AIDS/pages/tOAHIVRptgSP.aspx
CDPH 8641A (05/13)
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Download Form CDPH 8641A Adult Hiv/Aids Case Report Form - California

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