HIV/AIDS Pediatric Case Report Form - Pinellas County Health ...

I. HEALTH DEPT USE ONLY
Date Received at Health Department
___ ___/ ___ ___/ ___ ___ ___ ___
Document Source
Pediatric HIV/AIDS Confidential Case Report
(Patients < 13 years of age at time of diagnosis)
Surveillance Method
Did this report initiate a new case investigation?
Yes No Unknown
A_____-_____-_____-____ A F P R
Electronic Transfer CD/Disk
Report Status New Update Reporting Health Dept. City St. Petersburg
State Number
Report Medium Field Visit Mailed Faxed Phone
II. PATIENT IDENTIFIER INFORMATION-data not transmitted to CDC
Patient Name Last Name First Name Middle Name
Social Security Number
Address City County
State Zip Phone ( ) City/County Patient Number
III. DEMOGRAPHIC INFORMATION-complete ALL fields
Diagnostic Status Perinatal HIV Exposure Pediatric HIV Pediatric AIDS Pediatric Seroreverter
Sex assigned at Birth Male Female Date of Birth __ __/__ __/__ __ __ __ Status Alive Dead
Country of Birth US Other (specify):
Date of Death ___ ___/___ ___/___ ___ ___ ___
State/Territory of Death _________________________________
Ethnicity (select one): Hispanic/Latino Not Hispanic/Latino Unknown
Race: (select all that apply) Black/AA Asian Native American or Alaskan White Hawaiian/PI Unknown
Residence at Diagnosis: Same as Current Street Address:
City: County: State/Country: Zip:
IV. FACILITY OF DIAGNOSIS
V. PATIENT HISTORY- complete ALL fields
Facility Name:
Preceding the first positive HIV antibody test or AIDS diagnosis,
the child's biological mother had (Respond to ALL Categories)
Perinatally acquired HIV infection
Address: Injected non-prescription drugs
City:
HETEROSEXUAL relations with any of the following:
Yes No Unk
Intravenous/Injection Drug User……………………………………………….
Bisexual male ……………………………………
Transfusion recipient with documented HIV infection……………………….
Person with AIDS or documented HIV infection, risk unspecified…………..
Received transfusion of blood/blood components (other than clotting factor)
State/Country: Zip: Transplant recipient with documented HIV infection…………………………
First Date:____/____/____ Last Date:____/____/____
Received transplant of tissue/organs or artificial insemination
Facility Code:
Preceding the first positive HIV antibody test or AIDS diagnosis, the child had
Injected non-prescription drugs
Facility Setting (check one) Received clotting factor for hemophilia/coagulation disorder
Public Private Federal Other Specify Clotting
Date received (mm/dd/yyyy)
Provider Name (Last, First, MI)
Received transfusion of blood/blood components (other than clotting factor)
First Date:____/____/____ Last Date:____/____/____
Received transplant of tissue/organs
Provider Ph. No. ( )
Sexual contact with male
Med. Rec. No:
Sexual contact with female
Is pediatric sexual contact being investigated or considered as primary mode of exposure
Phone No. ( )
Other documented risk
Date form completed _____/_____/_______
Yes No Unk
Is transplant or artificial insemination being investigated or considered
Is pediatric sexual contact being investigated or considered as primary mode of exposure
Person Completing Form (Last, First, MI)
Is other exposure being investigated or considered as primary mode of exposure
Child's biological mother's HIV infection status:
Refused HIV testing
Known to be uninfected after this child's birth
HIV+, time of diagnosis unknown
Known HIV+ before pregnancy Known HIV+ at time of delivery Known HIV+ after the child's birth
Known HIV+ during pregnancy
Known HIV+ sometime before birth
HIV status unknown
Date of mother's first positive HIV confirmatory test Was the biological mother counseled about HIV testing during this pregnancy, labor or delivery?
(mm/dd/yyyy)
(circle one) Yes No Unknown
DH 2140, Rev 03/12

IX. TREATMENT/SERVICES REFERRALS
This child received or is receiving:
Neonatal zidovudine (ZDV, AZT) for HIV prevention
Other neonatal anti-retroviral medication for HIV prevention
If Yes, specify the medications:
Anti-retroviral therapy for HIV treatment
PCP prophylaxis
Was the child breastfed?
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
This child's primary □ Biological parents □ Foster/adoptive parent, relative □ Social service agency □ Unknown
caretaker is: □ Other relative □ Foster/adoptive parent, unrelated □ Other (if Other, please specify):
VI. LABORATORY DATA
HIV Antibody Tests at Diagnosis (Indicate first test - mm/dd/yyyy)
HIV-1 EIA
HIV-1/2 EIA
HIV -1/2 Ag/Ab
HIV-1/2 Differentiating
(e.g., Multispot)
HIV-1 RNA NASBA
HIV-1 RNA RT-PCR
Was patient confirmed by a physician as:
Positive
HIV- infected □ Yes □ No □ Unknown
Not HIV- infected □ Yes □ No □ Unknown
Negative
HIV-1 Western Blot/IFA
Other
Viral Load Test: ( most recent test- mm/dd/yyyy)
Type Name Copies / ML Collection Date
HIV-1 RNA bDNA
HIV-1 RNA Other
VII. CLINICAL STATUS
Clinical Record Reviewed? □ Yes □ No
Bacterial infection, multiple or recurrent (including
Salmonella septicemia)
Candidiasis, bronchi, trachea, or lungs
Candidiasis, esophageal
Coccidioidomycosis, disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic intestinal (>1 mo. duration)
Cytomegalovirus disease (other than in liver, spleen, or
nodes) onset at > 1 mo of age
Cytomegalovirus retinitis (with loss of vision)
HIV encephalopathy
Herpes simplex: chronic ulcer(s) (>1 mo. duration); or
bronchitis, pneumonitis or esophagitis onset>1 mo of age
Initial Dx Date
mm/dd/yy
Def.
Pres.
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
HIV Detection Tests: (Record earliest test-mm/dd/yyyy)
Positive
HIV-1 P24 Antigen
HIV-1RNA PCR (Qual)
HIV-1 Culture
HIV-1 Proviral DNA (Qual)
HIV-2 Culture
Other
Other
Immunologic Lab Test: (test date-mm/dd/yyyy)
At or closest to current diagnostic status
CD4 Count:____________ cells/ul (________%)
First1 mo. duration) ___/___/____ □ Wasting syndrome due to HIV
___/___/____ □
Has the child been diagnosed with pulmonary tuberculosis? □ Yes □ No □ Unknown
Def.
Pres.
If Yes, initial diagnosis and date
□ TB pre- 1993 □ Definitive □ Presumptive □ Unknown (mm/dd/yyyy)
RVCT Case Number
DH 2140, Rev 03/12

VIII. BIRTH HISTORY (for PERINATAL cases only)
Birth history available for this child:
□ Yes □ No □ Unknown
Residence at Birth: □ Same Address as patient address Address:
If No or Unknown, do not complete this section.
City: County: State/Country: Zip:
Hospital at Birth: Facility Name: Phone No: ( ) -
Address: City: County: State/Country: Zip:
Birth weight
Birth Type □ Single □ Twin □ > 2 □ Unknown
enter lbs/oz OR grams Birth Delivery □ Vaginal □ Elective Caesarean □ Non-elective Caesarean □ Caesarean, Unk type □ Unk
________ (lbs) Birth Defects □ Yes □ No □ Unknown
________ (oz) Specify:
________ (g) Code:
Neonatal Status: □ Full term □ Premature
Prenatal Care- Month of pregnancy when prenatal care began:
Prenatal Care- Total number of prenatal care visits
If Yes, specify types and enter codes, if known:
Specify:
Code:
Did mother receive zidovudine (ZDV, AZT) during pregnancy? □ Yes □ No □ Refused □ Unknown
If Yes, week of pregnancy when zidovudine (ZDV, AZT) began: Week ____________
(99=Unknown)
Did mother receive zidovudine (ZDV, AZT) during labor/delivery? □ Yes □ No □ Refused □ Unknown
Did mother receive zidovudine (ZDV, AZT) prior to this pregnancy? □ Yes □ No □Unknown
Did mother receive any other antiretroviral medication during pregnancy? □ Yes □ No □ Unknown
If Yes, specify:
Did mother receive any other antiretroviral medication during labor/delivery? □ Yes □ No □ Unknown
If Yes, specify:
Maternal Date of Birth
Maternal State Patient Number
Birthplace of Biological Mother
□ U.S. □ U.S. Minor Outlying Area: (specify)
□ Unknown □ Other: (specify)
X. LOCAL FIELDS (health department use only)
PRISM #
Link with eHARS stateno(s):
EPF____ EPF DATE_____________
SOURCE CODE A__________
No. of weeks (gestational age)
Maternal Soundex
(99-Unknown)
(99-Unknown) (00=None)
(99-Unknown) (00=None)
HEPATITIS: A____ B____ C____ Other____ Unknown_____
NIR STATUS: NIR_OP______ NIR OP DATE______________
NIR_ CL______ NIR CL DATE________________
OTHER RISKS: A____ B/C____ D____ F____ M____ V____ J____ NIR_RE_______ NIR RE DATE____________ Initials (3)________
XI. COMMENTS (e.g. birth mother history on drug use, STDs, mental illness, jail history, father, siblings, etc.)
DH 2140, REV. 03/12