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.

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?*

YesNoUnknown
Provide specimen collection date of earliest positive test result for this algorithm

MonthDayYear
Date
Is earliest evidence of HIV infection diagnosis documented by a physician rather than by laboratory test results?

YesNoUnknown
Provide date of diagnosis by physician

MonthDayYear
Date
Was there a negative HIV lab result prior to diagnosis?

YesNoUnknown
Date of last documented negative HIV test result (before HIV diagnosis date)*

MonthDayYear
Date
Specify type of test:
Testing Option (if applicable):

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).
Should be Empty:

HIV: Adult Case Report Form