HomeMy WebLinkAboutadult-hivaids-casereportformCDPH 8641A (05/13)Page 1 of 4
State of California - Health and Human Services Agency California Department of Public Health - Office of AIDS
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)
Street Address:City:County:State/Country:ZIP Code:Address of Residenceat HIV Diagnosis
Address of Residence
at AIDS Diagnosis
Street Address:City:County:State/Country:ZIP Code:
Residence at HIV Diagnosis Residence at AIDS Diagnosis Check if SAME as Current AddressAddress Type (check all that apply):
ADULT HIV/AIDS CASE REPORT FORM(Patients ≥ 13 Years of Age at Time of Diagnosis)
II. Patient Identification
First Name:Middle Name:Patient Last Name:
First Name:Middle Name:Last Name:Alternate Name Type (e.g. Alias, Married, etc.):
Address Type:
Current Street Address:
Phone Number:
City:County:
State/Country:ZIP Code:Social Security Number:Other ID Type #1:
Residential Bad Address Correctional Facility Foster Home Homeless Postal Shelter Temporary
( )
Other ID Type #1 Number:Other ID Type #2:Other ID Type #2 Number:
I. Health Department Use Only (See Appendix 1.0 for Further Details) (Record All Dates as mm/dd/yyyy)
Date Form Completed:
STATENO:CITYNO:
Reporting Health Department - City/County:
Surveillance Method:Active Passive
ReabstractionFollow Up Unknown
Document Source:
Report Medium:1- Field Visit 2- Mailed
3- Phone 4- Electronic Transfer 5- CD/Disk
Did this report initiate a new case investigation?
NoYes Unknown
Name of Person Completing Form:Person’s Phone Number:
( )
Physician’s Name:Physician’s Phone Number:
( )
Hospital/Facility Name:Report Status:
1- New 2- Update
_____/_____/________
III. Patient Demographics (See Appendix 2.0 for Further Details) (Record All Dates as mm/dd/yyyy)
Current Gender Identity:Transgender: Male-to-Female (MTF)
Sex Assigned at Birth:
FemaleMale Unknown
Country of Birth:
Other/U.S. Dependency (please specify):U.S.
Date of Birth:
Alias Date of Birth:Vital Status:
2- Dead1- Alive
Date of Death:
Race:Black/African American
Asian
White
Other (specify):
State of Death:
Transgender: Female-to-Male (FTM) Unknown
Other Gender Identity (specify):
Ethnicity:
Not Hispanic/Latino Unknown
Expanded Ethnicity:
Expanded Race:
American Indian/Alaskan Native
Pacific Islander
Samoan
Hawaiian
Guamanian
Filipino
Chinese
Japanese Asian Indian
Korean
Vietnamese
Laotian
Cambodian
Hispanic/Latino
HIV AIDS
Status:
Male Female
_____/_____/________
_____/_____/_____________/_____/________
Shaded Fields are Required. All Others are Optional.
CDPH 8641A (05/13)Page 2 of 4
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:NoYes Unknown Sex with a female:Injected non-prescription drugs:
HETEROSEXUAL relations with any of the following:
NoYes Unknown Received clotting factor for hemophilia/coagulation
disorder:
Received transfusion of blood/blood components
(non-clotting):
Other documented risk:
(if yes, specify):
NoYes Unknown NoYes Unknown
NoYes Unknown
NoYes Unknown
NoYes Unknown
NoYes Unknown
NoYes Unknown
NoYes Unknown
Has the patient:
Contact with intravenous/injection drug user (IDU):
Contact with a bisexual male:
Contact with a person with AIDS or documented HIV
infection, risk not specified:
Contact with transplant recipient with documented HIV:
Contact with transfusion recipient with documented HIV:NoYes Unknown
V. Facility at Diagnosis (See Appendix 4.0 for Further Details - Add Additional Facilities in Comments and Local/Optional Fields Section)
Street Address:Facility Name:
Facility Type:
City:
County:State/Country:ZIP Code:Provider Name:
Diagnosis Type (check all that apply to facility):HIV Diagnosis AIDS Diagnosis Check if SAME as Facility Providing Information
Phone Number:
( )
HospitalInpatient:Other (specify):
Private PhysicianOutpatient:Other (specify):Adult HIV Clinic
CTSScreening, Diagnostic, Referral Agency:Other (specify):STD Clinic
Emergency RoomOther Facility:Other (specify):Laboratory Corrections Unknown
Manufacturer:
VII. Laboratory Data (Record All Dates as mm/dd/yyyy) (See Instructions for Details)
HIV Antibody Tests (Type Differentiating) [HIV-1 vs. HIV-2]
TEST:
RESULT:
HIV-1/2 Differentiating (e.g. Multispot)
HIV-1 HIV-2 Both (undifferentiated)Neither (negative)
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
Positive/Reactive Negative/Nonreactive Indeterminate RAPID TEST (check if rapid):Collection Date:
Other (specify test):
_____/_____/________
Collection Date:_____/_____/________
RESULT:
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
Positive/Reactive Negative/Nonreactive Indeterminate RAPID TEST (check if rapid):Collection Date:
Other (specify test):
_____/_____/________
RESULT:
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
Positive/Reactive Negative/Nonreactive Indeterminate RAPID TEST (check if rapid):Collection Date:
Other (specify test):
_____/_____/________
RESULT:
STATENO:
CDPH 8641A (05/13)Page 3 of 4
VIII. Clinical (Check Boxes Where Applicable) (Record All Dates as mm/dd/yyyy)
Pneumocystis carinii pneumonia
Candidiasis, esophageal
Wasting syndrome due to HIVCytomegalovirus disease (other than in liver, spleen or nodes)
Kaposi’s sarcoma
Herpes simplex: chronic ulcer(s) (>1 mo. duration),
bronchitis, pneumonitis or esophagitis
Cryptococcosis, extrapulmonary
Other (specify):
Date Date
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?NoYes 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?NoYes Unknown
If yes, provide date of documentation by physician:_____/_____/________
VII. Laboratory Data (continued) (Record All Dates as mm/dd/yyyy)
HIV Detection Tests (Qualitative)
HIV Detection Tests (Quantitative Viral Load) Note: Include earliest test after diagnosis
TEST 1:
Immunologic Tests (CD4 Count and Percentage)
HIV-1 RNA/DNA NAAT (Qual)HIV-1 P24 Antigen HIV-1 Culture HIV-2 RNA/DNA NAAT (Qual)HIV-2 Culture
Positive/Reactive Negative/Nonreactive Indeterminate
HIV-1 RNA/DNA NAAT (Quantitative Viral Load)
Detectable Undetectable Copies/mL:Log:
RT-PCR bDNA Other (specify test):
Collection Date:_____/_____/________
Collection Date:_____/_____/________
RESULT:
TEST 2:HIV-1 RNA/DNA NAAT (Qual)HIV-1 P24 Antigen HIV-1 Culture HIV-2 RNA/DNA NAAT (Qual)HIV-2 Culture
Positive/Reactive Negative/Nonreactive Indeterminate Collection Date:_____/_____/________RESULT:
TEST 1:
RESULT:
TEST 2:
RESULT:
HIV-1 RNA/DNA NAAT (Quantitative Viral Load)
Detectable Undetectable Copies/mL:Log:
RT-PCR bDNA Other (specify test):
Collection Date:_____/_____/________
CD4 at or closest to current diagnosis status:CD4 count: cells/µL CD4 percentage: %Collection Date:_____/_____/________
First CD4 result <200 cells/µL or <14%:CD4 count: cells/µL CD4 percentage: %Collection Date:_____/_____/________
Other CD4 result <200 cells/µL or <14%:CD4 count: cells/µL CD4 percentage: %Collection Date:_____/_____/________
IX. Treatment/Services Referrals (Record All Dates as mm/dd/yyyy)
Has This Patient Been Informed of His/Her HIV Infection?NoYes Unknown
For Female Patient:
Is This Patient Currently Pregnant?Has This Patient Delivered Live-Born Infants?
Patient’s Medical Treatment is Primarily Reimbursed by:
1- Medicaid 2- Private Insurance/HMO 3- No Coverage 4- Other Public Funding 9- Unknown
NoYes Unknown NoYes Unknown
STATENO:
CDPH 8641A (05/13)Page 4 of 4
XII. Comments and Local/Optional Fields
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
LOCAL HEALTH DEPARTMENTS:SUBMIT COMPLETED FORM TO THE OFFICE OF AIDS PER YOUR CONTRACT’S SCOPE OF WORK, EXHIBIT A, PART D, OBJECTIVE 2.
XI. Duplicate Review
Status (check one):Same As Different Than Pending State Name:STATENO:
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 Name:Phone Number:
Street Address:City:
County:State/Country:ZIP Code:
( )
Hospital of Birth: (If Child Was Born at Home, Enter “Home Birth” for Hospital Name)
IX. Treatment/Services Referrals (continued) (Record All Dates as mm/dd/yyyy)
______/______/________
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 (select one):Patient Interview Medical Record Review
Provider Report NHM&E/PEMS Other (specify):
Ever Taken Any Antiretrovirals (ARVs)?If Yes, What ARV Medications?
Date ARVs First Taken:Date ARVs Last Taken (mm/dd/yyyy):
Don’t Know/UnknownRefusedNumber of Negative HIV Tests Within 24 Months Before First Positive Test (#):
Ever Had a Negative HIV Test?Date of Last Negative HIV Test: (If date is from a lab test
with test type, enter in
Laboratory Data Section.)
Date Patient Reported Information:
Ever Had a Positive HIV Test?
Don’t Know/Unknown
RefusedYesNo
Date of First Positive HIV Test:
_____/_____/________
_____/_____/_____________/_____/________
_____/_____/_____________/_____/________
Don’t Know/Unknown
RefusedYesNo
Don’t Know/Unknown
RefusedYesNo
STATENO: