HIV Adult Case Report Form

  • HIV: Adult Case Report Form

    This Form was adapted from the CDC 50.42A, CDC Rev. 1/2023, DPHHS Rev. 5/2024

  • If you have any questions on this form or case investigation, please contact HIV Surveillance at 406-444-4735 or HIV Prevention at 406-444-3565

    This form should be used only for patients >13 years of age at the time of diagnosis. Please contact the HIV Surveillance program for a pediatric case report form if needed.

  • 1. Patient Identification

    (Please record all dates as mm/dd/yyyy)
  • Address Type*
  • Address Date
     - -
  • Format: (000) 000-0000.

  • 2. Health Department Use Only

  • Do you work at DPHHS?*
  • Date Received at Health Department
     - -
  • Surveillance Method
  • Did this report initiate a new case investigation?
  • Report Medium

  • 3. Local Health Department or Facility Providing Information

  • Format: (000) 000-0000.
  • Outpatient
  • Screening, Diagnostic, Referral Agency
  • Other Facility
  • Date Form Completed*
     - -
  • Format: (000) 000-0000.

  • 4. Patient Demographics

  • Sex*
  • Date of Birth*
     - -
  • Alias Date of Birth
     - -
  • Vital Status*
  • Date of Death
     - -
  • Gender Identity*
  • Gender Identity Date Identified - If date is unknown, please use the date of the interview.
     - -
  • Sexual Orientation*
  • Sexual Orientation Date Identified - If date is unknown, please use the date of the interview.
     - -
  • Ethnicity*
  • Race (check all that apply)*

  • 5. Residence at Diagnosis

    (add additional addresses in Comments)
  • Address Type (check all that apply to address)*
  • Address Type*

  • 6. Facility of Diagnosis

    (add additional facilities in Comments)
  • Format: (000) 000-0000.
  • Outpatient
  • Screening, Diagnostic, Referral Agency
  • Other Facility

  • 7. Patient History

    (respond to all questions)

  • After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
  • Sex with male*
  • Sex with Female*
  • Injected nonprescription drugs*
  • Received clotting factor for hemophilia/coagulation disorder*
  • Date received
     - -

  • HETEROSEXUAL relations with any of the following:
  • Heterosexual contact with person who injected drugs*
  • Heterosexual contact with bisexual male*
  • Heterosexual contact with person with hemophilia/coagulation disorder with documented HIV infection*
  • Heterosexual contact with transfusion recipient with documented HIV infection*
  • Heterosexual contact with transplant recipient with documented HIV infection*
  • Heterosexual contact with person with documented HIV infection, risk not specified*
  • Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments)*
  • First date received
     - -
  • Last date received
     - -
  • Received transplant of tissue/organs or artificial insemination*
  • Worked in a healthcare or clinical laboratory setting*
  • Other documented risk*

  • 8. Clinical

    Acute HIV Infection and Opportunistic Illnesses
  • Suspect acute HIV infection?*
  • Clinical signs/symptoms consistent with acute retroviral syndrome (e.g., fever, malaise/fatigue, myalgia, pharyngitis, rash, lymphadenopathy)*
  • Date of sign/symptom onset
     - -
  • Other evidence suggestive of acute HIV infection?
  • Date of evidence
     - -
  • Does this patient have any opportunistic illnesses related to HIV?
  • Candidiasis, bronchi, trachea, or lungs Dx date
     - -
  • Candidiasis, esophageal Dx date
     - -
  • Carcinoma, invasive cervical Dx date
     - -
  • Coccidioidomycosis, disseminated or extrapulmonary Dx date
     - -
  • Cryptosporidiosis, extrapulmonary Dx date
     - -
  • Cryptosporidiosis, chronic intestinal (>1 mo. duration) Dx date
     - -
  • Cytomegalovirus disease (other than in liver, spleen, or nodes) Dx date
     - -
  • Cytomegalovirus retinitis (with loss of vision) Dx date
     - -
  • HIV encephalopathy Dx date
     - -
  • Herpes simplex: chronic ulcers (>1 mo. duration), bronchitis, pneumonitis, or esophagitis Dx date
     - -
  • Histoplasmosis, disseminated or extrapulmonary Dx date
     - -
  • Isosporiasis, chronic intestinal (>1 mo. duration) Dx date
     - -
  • Kaposi's sarcoma Dx date
     - -
  • Lymphoma, Birkitt's (or equivalent) Dx date
     - -
  • Lymphoma, immunoblastic (or equivalent) Dx date
     - -
  • Lymphoma, primary in brain Dx date
     - -
  • Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary Dx date
     - -
  • M. tuberculosis, pulmonary Dx date
     - -
  • M. tuberculosis, disseminated or extrapulmonary Dx date
     - -
  • Mycobacterium, of other/unidentified species, disseminated or extrapulmonary Dx date
     - -
  • Pneumocystis pneumonia Dx date
     - -
  • Pneumonia, recurrent, in 12 mo. period Dx date
     - -
  • Progressive multifocal leukoencephalopathy Dx date
     - -
  • Salmonella septicemia, recurrent Dx date
     - -
  • Toxoplasmosis of brain, onset at >1 mo. of age Dx date
     - -
  • Wasting syndrome due to HIV Dx date
     - -

  • 9. Laboratory Data

    (record additional tests and tests not specified below in comments)

  • HIV diagnostic algorithm can be found here. 

  • Did documented laboratory test results meet approved HIV diagnostic algorithm criteria?*
  • Provide specimen collection date of earliest positive test result for this algorithm
     - -
  • Is earliest evidence of HIV infection diagnosis documented by a physician rather than by laboratory test results?
  • Provide date of diagnosis by physician
     - -
  • Was there a negative HIV lab result prior to diagnosis?
  • Date of last documented negative HIV test result (before HIV diagnosis date)*
     - -

  • 10. Treatment/Services Referrals

  • Has this patient been informed of his/her HIV infection?*
  • This patient's partners will be notified about their HIV exposure and counseled by*
  • Evidence of receipt of HIV medical care other than laboratory test result (select one; record additional evidence in Comments)
  • Date of medical visit or prescription
     - -
  • This patient is receiving or has been referred for gynecological or obstetrical services
  • Is this patient currently pregnant?
  • Has this patient delivered live-born infants?
  • Is child exposed?
  • Child's Date of Birth
     - -
  • Format: (000) 000-0000.
  • Other Facility

  • 11. Antiretroviral Use History

  • Main source of antiretroviral (ARV) use information*
  • Date patient reported information*
     - -
  • Ever taken any antiretroviral(s) (ARVs)?*
  • If yes, reason for ARV use (select all that apply)
  • Date began:
     - -
  • Date of last use:
     - -
  • Date began:
     - -
  • Date of last use:
     - -
  • Date began:
     - -
  • Date of last use:
     - -
  • Date began:
     - -
  • Date of last use:
     - -

  • 12. HIV Testing History

  • Main source of testing history information*
  • Date patient reported information*
     - -
  • Ever had a previous positive HIV test result?*
  • Date of first positive HIV test result*
     - -
  • Was the first positive test result from a self-test performed by patient?*
  • Ever had a negative HIV test result?*
  • Date of last negative HIV test result*
     - -
  • Was the last negative test result from a self-test performed by the patient?*

  • 13. Comments Section

  • Submission Page

    This report to CDC is authorized by law (Sections 304 and 306 of the Public Health Service Act, 42USC 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, and will not otherwise be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public HealthService Act (42 USC 242m).
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