• 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
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • 2. Health Department Use Only

  • Do you work at DPHHS?*
  • Date Received at Health Department
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • 4. Patient Demographics

  • Sex*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Alias Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Vital Status*
  • Date of Death
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender Identity*
  • Gender Identity Date Identified - If date is unknown, please use the date of the interview.
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sexual Orientation*
  • Sexual Orientation Date Identified - If date is unknown, please use the date of the interview.
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last date received
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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
     - -
    2 digit month, 2 digit day, 4 digit year
  • Other evidence suggestive of acute HIV infection?
  • Date of evidence
     - -
    2 digit month, 2 digit day, 4 digit year
  • Does this patient have any opportunistic illnesses related to HIV?
  • Candidiasis, bronchi, trachea, or lungs Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Candidiasis, esophageal Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Carcinoma, invasive cervical Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Coccidioidomycosis, disseminated or extrapulmonary Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Cryptosporidiosis, extrapulmonary Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Cryptosporidiosis, chronic intestinal (>1 mo. duration) Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Cytomegalovirus disease (other than in liver, spleen, or nodes) Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Cytomegalovirus retinitis (with loss of vision) Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • HIV encephalopathy Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Herpes simplex: chronic ulcers (>1 mo. duration), bronchitis, pneumonitis, or esophagitis Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Histoplasmosis, disseminated or extrapulmonary Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Isosporiasis, chronic intestinal (>1 mo. duration) Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Kaposi's sarcoma Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Lymphoma, Birkitt's (or equivalent) Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Lymphoma, immunoblastic (or equivalent) Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Lymphoma, primary in brain Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • M. tuberculosis, pulmonary Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • M. tuberculosis, disseminated or extrapulmonary Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Mycobacterium, of other/unidentified species, disseminated or extrapulmonary Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Pneumocystis pneumonia Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Pneumonia, recurrent, in 12 mo. period Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Progressive multifocal leukoencephalopathy Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Salmonella septicemia, recurrent Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Toxoplasmosis of brain, onset at >1 mo. of age Dx date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Wasting syndrome due to HIV Dx date
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is earliest evidence of HIV infection diagnosis documented by a physician rather than by laboratory test results?
  • Provide date of diagnosis by physician
     - -
    2 digit month, 2 digit day, 4 digit year
  • Was there a negative HIV lab result prior to diagnosis?
  • Date of last documented negative HIV test result (before HIV diagnosis date)*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Other Facility

  • 11. Antiretroviral Use History

  • Main source of antiretroviral (ARV) use information*
  • Date patient reported information*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Ever taken any antiretroviral(s) (ARVs)?*
  • If yes, reason for ARV use (select all that apply)
  • Date began:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last use:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date began:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last use:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date began:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last use:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date began:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last use:
     - -
    2 digit month, 2 digit day, 4 digit year

  • 12. HIV Testing History

  • Main source of testing history information*
  • Date patient reported information*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Ever had a previous positive HIV test result?*
  • Date of first positive HIV test result*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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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