51202

I.
PATIENT INFORMATION
Patients Name: ___________________________________________________________________________________ Phone No.: (
(Last, First, M.I.)
Address:
_________________________
__________________________
Zip
_________________________
County:
_______________ State: _________ Code: ______________________
Social Security No.: ______________________________ - Patient identifier information is not transmitted to CDC! -
City:
RETURN TO STATE/LOCAL HEALTH DEPARTMENT
INDIANA STATE DEPARTMENT OF HEALTH

PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT
(Patients <13 years of age at time of diagnosis)
State Form 51202 (12-02)
DATE FORM COMPLETED
Mo.
Day
Yr.
II. STATE HEALTH DEPARTMENT USE ONLY

SOUNDEX
CODE:
REPORT STATUS:
REPORT SOURCE:
New Report
Update
REPORTING HEALTH
DEPARTMENT:
State:
State
Patient No.:
_________________________________
City/
County: ________________________________
City/County
Patient No.:
III. DEMOGRAPHIC INFORMATION

3 Perinatally HIV Exposed
4 Confirmed HIV Infection (not AIDS)
DIAGNOSTIC STATUS AT REPORT:

(check one)
DATE OF BIRTH:
Mo.
CURRENT STATUS:
AGE AT DIAGNOSIS:
Day
Years
Yr.
5
6
Months
HIV Infection
(not AIDS)
Alive
Dead
Unk.
AIDS
Seroreverter
STATE/TERRITORY OF DEATH:
DATE OF DEATH:
Mo.
Day
Yes
1
No
Unk.
Yr.
DATE OF INITIAL EVALUATION

FOR HIV INFECTION:
Mo.
Yr.
Yr.
________________________
AIDS
Was reason for initial HIV
evaluation due to clinical
signs and symptoms?
Mo.
DATE OF LAST MEDICAL EVALUATION:
SEX:
ETHNICITY (select one):
RACE (select one or more):
COUNTRY OF BIRTH:
1 U.S.
Male
Female
1 Hispanic or Latino
American Indian
or Alaska Native
Asian
Not Hispanic or Latino
Black or African
American
Native Hawaiian/or
Other Pacific Islander
Unknown
White
Unknown
7 U.S. Dependencies and Possessions (incl.

Puerto Rico)
(specify): _______________________________
8 Other (specify):
9 Unk.
____________________________
RESIDENCE AT DIAGNOSIS:
State/
Zip
City: ________________________________________ County: ____________________________________ Country: ______________________________ Code:
IV. FACILITY OF DIAGNOSIS

Facility
State/
Name: _____________________________________________________________________________ City: _____________________________________ Country: __________________________________
FACILITY SETTING (check one):
1
Public
Private
FACILITY TYPE (check one):

3
Federal
Unk.
01
Physician, HMO
31
Hospital, Inpatient
32
Hospital, Outpatient
88
Other (specify): ______________
V. PATIENT/MATERNAL HISTORY (Respond to ALL categories)

* Childs biologic mothers HIV infection status (check one):
Biologic mother diagnosed with HIV Infection/AIDS:
Refused HIV testing
Known to be uninfected after this childs birth
Known to be uninfected after this childs birth
After the childs birth
HIV status unknown
At time of delivery
HIV-infected, unknown when diagnosed
Mo.
Before this childs pregnancy
Yr.
during this pregnancy, labor, or delivery?

Yes
No
Unk.
Injected nonprescription drugs .
HETEROSEXUAL relations with:

- Intravenous/injection drug user .
- Bisexual male ...
- Male with hemophilia/coagulation disorder .
- Transfusion recipient with documented HIV infection
- Transplant recipient with documented HIV infection ..

- Male with AIDS or documented HIV infection, risk not specified ..
1
1
0
0
Yes
No
Unk.
Yes
No
Unk.
Before
Beforethe
thediagnosis
diagnosisofofHIV
HIVInfection/AIDS,
Infection/AIDS,this
thischild
childhad:
had:
Received clotting factor for hemophilia/coagulation disorder:
1
0
9
(specify
1 Factor VIII (Hemophilia A)
2
Factor IX (Hemophilia B)
disorder):
8 Other (specify):
______________________________________________________
Yes
No
Unk.
Received transfusion of blood/blood components
(other than clotting factor):
1
0
9
Mo.
Mo.
Yr.
Yes
No
Unk.
Sexual contact with a male ..
Sexual contact with a female ..
Injected nonprescription drugs
Other (Alert State Health Department) ...
Received transplant of tissue/organs or artificial insemination
First:
Yr.
Received transplant of tissue/organs .
Received transfusion of blood/blood components .

(other than clotting factor)
CDC 50.42B REV. 01/2003 (Page 1 of 4)
Before Childs birth, exact period unknown
* Mother was counseled about HIV testing
*Date of mothers first positive HIV confirmatory test:

After 1977, this childs biologic mother had:
Last:
- PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT -
(Indiana Rev. 01/2003)
VI. PHYSICIANs INFORMATION

Infants Physicians Name: _______________________________________________ Phone No.: (
Medical
) ________________________ Record No. _________________________
(Last, First, M.I.)
Person
Hospital/Facility: ____________________________________________ Completing Form: __________________________________Phone No.: (
) _____________________
- Physician identifier information is not transmitted to CDC! VII. LABORATORY DATA

1. HIV antibody tests at diagnosis: (Record all tests, include earliest positive)
Negative
Indeterminate
Not Done
HIV-1 EIA .....
Positive
1
HIV-1 EIA ..
HIV-1 Western blot/IFA ...
HIV-1 Western blot/IFA ...
Other HIV antibody test (specify):
TEST DATE
Mo.
Yr.
2. HIV DETECTION TESTS:

(Record all tests, include earliest positive)
TEST DATE
Mo.
Yr.
Negative
0
Not
Done
9
HIV RNA PCR..
HIV RNA PCR.
Other, Specify: _______________
Positive
Negative
HIV culture ..
Not
Done
9
HIV culture ..
HIV DNA PCR..
HIV antigen test .
HIV antigen test .
3. HIV VIRAL LOAD TEST: (Record all tests, include earliest detectable)
Test type*
Detectable
Yes
No
1
0
*Type: 11. NASBA (Organon)

Test Date
Mo.
Yr.
Copies/ml
4. IMMUNOLOGIC LAB TESTS: (At or closest to current diagnostic status)

Mo.
CD4 Count .
CD4 Count .
Positive
HIV DNA PCR..
1
Yr.
Test type*
Detectable
Yes
No
1
0
13. bDNA (Chiron)
18. Other
Test Date
Mo.
Yr.
Copies/ml
5. If HIV tests were not positive or were not done, or the patient is less than 18 months of age, does
this patient have an immunodeficiency that would disqualify him/her from the AIDS case definition?
cells/L
12. RT-PCR (Roche)
TEST DATE
Mo.
Yr.
Yes
No
Unk.
Specify: ______________________________________
cells/L
6. If laboratory tests were not documented,
is patient confirmed by a physician as:
CD4 Percent ..
CD4 Percent ..
HIV-infected ..
Yes
1
No
0
Unk.
9
Not HIV-infected ...
Date of Documentation
Mo.
Yr.
VIII. CLINICAL STATUS

AIDS INDICATOR DISEASES
Bacterial infections, multiple or recurrent .
(including Salmonella septicemia)
Initial Diagnosis
Def.
Pres.
1
NA
Initial Date
Mo.
Yr.
AIDS INDICATOR DISEASES

Kaposis sarcoma ..
Initial Diagnosis
Def.
Pres.
1
2
NA
Lymphoid interstitial pneumonia and/or .

pulmonary lymphoid hyperplasia
Lymphoma, Burkitts (or equivalent term) .
NA
NA
Lymphoma, immunoblastic (or equivalent term) ..
NA
Cryptococcosis, extrapulmonary
NA
Lymphoma, primary in brain
NA
Cryptosporidiosis, chronic intestinal ..

(>1 mo. duration)
NA
Mycobacterium avium complex or M. kansasii,

disseminated or extrapulmonary
Cytomegalovirus disease (other than in liver, ..

spleen, or nodes) onset at >1 mo. of age
NA
M. tuberculosis, pulmonary*
M. tuberculosis, disseminated or extrapulmonary* ..
Cytomegalovirus retinitis (with loss of vision) ...
HIV encephalopathy .
NA
Mycobacterium, of other species or unidentified .

species, disseminated or extrapulmonary
Herpes simplex: chronic ulcer(s) (>1 mo. duration);

or bronchitis, pneumonitis or esophagitis, onset at
>1 mo. of age
NA
Pneumocystis carinii pneumonia
Progressive multifocal leukoencephalopathy ...
NA
Histoplasmosis, disseminated or extrapulmonary ...
NA
Toxoplasmosis of brain, onset at >1 mo. of age ..
Isosporiasis, chronic intestinal (>1 mo. duration) ....
NA
Wasting syndrome due to HIV
NA
Candidiasis, bronchi, trachea, or lungs
Candidiasis, esophageal .
Coccidioidomycosis, disseminated or ...
extrapulmonary
Def. = definitive diagnosis
CDC 50.42B REV. 01/2003 (Page 2 of 4)
Pres. = presumptive diagnosis
Initial Date
Mo.
Yr.
*RVCT CASE NO:
IX. BIRTH HISTORY (for PERINATAL cases only)

Birth history was available for this child:
Yes
No
Unk.
If No or Unknown, proceed to Section X.
HOSPITAL AT BIRTH:
Hospital: ____________________________________________________________
City: ______________________________
State: _______________________
Zip
Cod
e:
RESIDENCE AT BIRTH:
City: ___________________________
BIRTHWEIGHT:
State/
Country: __________________________
County: ____________________________
BIRTH:
(enter lbs/oz OR grams)

lbs.
oz.
1 Single
DELIVERY:
2 Twin
1 Vaginal
3 >2
Elective
Caesarean
Unk.
Non-elective
Caesarean
Full term
Premature
PRENATAL CARE:
Mo.
Weeks:
(99=Unk.)
grams
4 Caesarean, unk. type
BIRTH DEFECTS:
1 Yes
Yes
No
Refused
Unk.
Month of pregnancy
prenatal care began:
99=Unk.
00=None
Total number of
prenatal care visits:
99=Unk.
00=None
Unk.
0 No
Specify type(s):
____________________________
Did mother receive

zidovudine (ZDV, AZT)
during pregnancy? .
NEONATAL STATUS:
TYPE:
Country: ______________________
Unk.
Code:
Did mother receive

zidovudine (ZDV,
AZT) during
labor/delivery? .
Yes
No
Refused
Unk.
Did mother receive

any other
Anti-retroviral
medication
during pregnancy?
Yes
1
No
0
Unk.
9
If yes, specify: _____________________________________
If yes, what week of

pregnancy was zidovudine
(ZDV, AZT) started? ..
Did mother receive

zidovudine (ZDV, AZT)
prior to this
pregnancy? .
Week
99=Unk.
Yes
No
Unk.
Did mother receive

any other
Anti-retroviral
Yes
medication
1
during labor/delivery
No
0
Unk.
9
If yes, specify: _____________________________________
X. INFORMATION ON MOTHER / FATHER

Maternal Date of Birth
Mo.
Day
Maternal State Patient No.
Maternal
Soundex:
____________________________________________________
(Mothers Name)
Yr.
____________________________________________________
(Fathers Name)
Fathers HIV Status (check one):
Positive
Negative
Unk.
Birthplace of Biologic Mother:

1
U.S.
U.S. Dependencies and Possessions (including Puerto Rico) (specify): ______________________________________________________________________________________
Other (specify): _________________________________________________________________________________________________
Unk.
XI. TREATMENT/SERVICES REFERRALS

This child received or is receiving:
Yes
No
Unk.
Neonatal zidovudine
(ZDV, AZT) for HIV
prevention
Anti-retroviral therapy
for HIV treatment
PCP prophylaxis
Mo.
DATE STARTED
Day
Was child breastfed?
This child has been enrolled at:
Yr.
Yes
No
Unk.
Clinical Trial
Medicaid
NIH-sponsored
Other
Private insurance/HMO
None
Unk.
No coverage
Other Public Funding
Clinical trial/
government program
Unk.
Clinic
Other neonatal anti1

0
9
retroviral medication
for HIV prevention
If yes, specify: ______________________________
This childs medical treatment is

primarily reimbursed by:
HRSA-sponsored
Other
None
Unk.
This childs primary caretaker is:

1 Biologic
parent(s)
2 Other
relative
3 Foster/Adoptive
parent, relative
4 Foster/Adoptive
parent, unrelated
Social service
agency
8 Other
(specify in Section XI.)
Unk.
Public burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently
valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer,
1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0009). DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS.
CDC 50.42B REV. 01/2003 (Page 3 of 4)
XII. COMMENTS
STATE USE ONLY

NIR STATUS: This section is used only if a case has been previously entered
as NIR or is being entered NIR. Choose response that corresponds to the
current status.
NIR:
Yes
No
Current Status:
Casework done to complete report
1=
2=
3=
4=
5=
6=
01 =
02 =
03 =
04 =
05 =
06 =
07 =
08 =
09 =
Open (still seeking risk)

Closed Dead*
Closed Refused*
Closed Lost to follow-up*
Investigated (risk still unknown)*
Reclassified (risk has been found)*
Current Physician
*Enter month/year resolved: __________/__________
Send packet
Arrived complete
Demographic data
Residence at Dx
Hospital/Facility
Risk factor
Date of first Dx
Laboratory data
Physician info
Case report
Current Address
Casework done to complete report
MCHD
LCHD
Other
CLOSED Q&A
Sent to DIS
RETURN TO SURVEILLANCE COORDINATOR
CDC 50.42B REV. 01/2003 (Page 4 of 4)
1=
2=
3=
4=
5=
1-2 calls
2-4 calls
5-10 calls
investigated to DIS (See NIR section)
other
Surv. Coord. initials

Follow-up date
Follow-up plan

51202

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I.

RETURN TO STATE/LOCAL HEALTH DEPARTMENT

INDIANA STATE DEPARTMENT OF HEALTH

II. STATE HEALTH DEPARTMENT USE ONLY

III. DEMOGRAPHIC INFORMATION

DIAGNOSTIC STATUS AT REPORT:

DATE OF INITIAL EVALUATION

DATE OF LAST MEDICAL EVALUATION:

ETHNICITY (select one):

RACE (select one or more):

Not Hispanic or Latino

7 U.S. Dependencies and Possessions (incl.

IV. FACILITY OF DIAGNOSIS

FACILITY TYPE (check one):

Other (specify): ______________

V. PATIENT/MATERNAL HISTORY (Respond to ALL categories)

Biologic mother diagnosed with HIV Infection/AIDS:

Refused HIV testing

Known to be uninfected after this childs birth

Known to be uninfected after this childs birth

After the childs birth

HIV status unknown

HIV-infected, unknown when diagnosed

Before this childs pregnancy

during this pregnancy, labor, or delivery?

Injected nonprescription drugs .

HETEROSEXUAL relations with:

- Bisexual male ...

- Male with hemophilia/coagulation disorder .

- Transfusion recipient with documented HIV infection

- Transplant recipient with documented HIV infection ..

Sexual contact with a male ..

Sexual contact with a female ..

Injected nonprescription drugs

Other (Alert State Health Department) ...

Received transplant of tissue/organs or artificial insemination

Received transplant of tissue/organs .

Received transfusion of blood/blood components .

CDC 50.42B REV. 01/2003 (Page 1 of 4)

Before Childs birth, exact period unknown

* Mother was counseled about HIV testing

*Date of mothers first positive HIV confirmatory test:

- PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT -

(Indiana Rev. 01/2003)

VI. PHYSICIANs INFORMATION

(Last, First, M.I.)

- Physician identifier information is not transmitted to CDC! VII. LABORATORY DATA

HIV-1 EIA .....

HIV-1 Western blot/IFA ...

HIV-1 Western blot/IFA ...

Other HIV antibody test (specify):

2. HIV DETECTION TESTS:

HIV RNA PCR..

HIV RNA PCR.

Other, Specify: _______________

HIV DNA PCR..

HIV antigen test .

HIV antigen test .

*Type: 11. NASBA (Organon)

4. IMMUNOLOGIC LAB TESTS: (At or closest to current diagnostic status)

13. bDNA (Chiron)

12. RT-PCR (Roche)

Not HIV-infected ...

VIII. CLINICAL STATUS