CDC 50.42A Rev. 01/2023 (Page 1 of 4) —ADULT HIV CONFIDENTIAL CASE REPORT—
I. Patient Identification (record all dates as mm/dd/yyyy)
*First Name
*Middle Name
*Last Name
Last Name Soundex
Alternate Name Type (ex: Alias, Married)
*First Name
*Middle Name
*Last Name
□ Foster home □ Homeless □ Military □ Other
*Current Address, Street
Address Date
/
/
*Phone
( )
City
County
State/Country
*ZIP Code
*Medical Record Number
*Other ID Type *Number
U.S. Department of Health
and Human Services
Adult HIV Confidential Case Report Form
Centers for Disease Control
and Prevention (CDC)
(Patients >13 years of age at time of diagnosis) *Information NOT transmitted to CDC
II. Health Department Use Only (record all dates as mm/dd/yyyy) Form approved OMB no. 0920-0573 Exp. 02/28/2026
Date Received at Health Department
/
/
eHARS Document UID
State Number
Reporting Health Dept—City/County
City/County Number
Document Source
Surveillance Method □ Active □ Passive □ Follow up □ Reabstraction □ Unknown
Did this report initiate a new case investigation?
□ Yes □ No □ Unknown
Report Medium
□ 1-Field visit □ 2-Mailed □ 3-Faxed □ 4-Phone □ 5-Electronic transfer □ 6-CD/disk
III. Facility Providing Information (record all dates as mm/dd/yyyy)
Facility Name
*Phone
( )
*Street Address
City
County
State/Country
*ZIP Code
Facility
Inpatient:
Outpatient:
□
Private physician’s office
Screening, Diagnostic, Referral Agency:
Other Facility
:
□
Emergency room
Type
□
Hospital
□
Adult HIV clinic
□
CTS
□
STD clinic
□ Laboratory □ Corrections □ Unknown
□
Other, specify
□
Other, specify
□
Other, specify
□
Other, specify
Date Form Completed
/
/
*Person Completing Form *Phone
( )
IV. Patient Demographics (record all dates as mm/dd/yyyy)
Sex Assigned at Birth □ Male □ Female □ Unknown
Country of Birth □ US □ Other/US dependency (specify)
Date of Birth
/ /
Alias Date of Birth
/ /
Vital Status □ 1-Alive □ 2-Dead
Date of Death / /
State of Death
Gender Identity
□ Man □ Woman □ Transgender man □ Transgender woman
□ Additional gender identity (specify)
□ Declined to answer □ Unknown
Date Identified
/ /
Sexual Orientation
□
Straight or heterosexual
□
Lesbian or gay
□
Bisexual
□ Additional sexual orientation (specify)
□ Declined to answer □ Unknown
Date Identified
/ /
Ethnicity
□ Hispanic/Latino □ Not Hispanic/Latino □ Unknown
Expanded Ethnicity
Race
(check all that apply)
□
American Indian/Alaska Native
□
Asian
□
Black/African American
□ Native Hawaiian/Other Pacific Islander □ White □ Unknown
Expanded Race
V. Residence at Diagnosis (add additional addresses in Comments) (record all dates as mm/dd/yyyy)
Address Event Type
(check all that apply to address below) □ Residence at HIV diagnosis □ Residence at stage 3 (AIDS) diagnosis □ Check if SAME as current address
Address Type
□
Residential
□
Bad address
□
Correctional facility
□
Foster home
□
Homeless
□
Military
□
Other
□
Postal
□
Shelter
□
Temporary
*Street Address
City
County
State/Country
*ZIP Code
Public reporting burden of this collection of information is estimated to average 20 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-74, Atlanta, GA 30333, ATTN: PRA (0920-0573). Do not send the completed form to this address.
CDC 50.42A Rev. 01/2023 (Page 2 of 4) —ADULT HIV CONFIDENTIAL CASE REPORT—
VI. Facility of Diagnosis (add additional facilities in Comments)
Diagnosis Type
(check all that apply to facility below)
□
HIV
□
Stage 3 (AIDS)
□
Check if SAME as facility providing information
Facility Name
*Phone ( )
*Street Address
City
County
State/Country
*ZIP Code
Facility Type
Inpatient:
□ Hospital
□ Other, specify
Outpatient
:
□ Private physician’s office
□
Adult HIV clinic
□
Other, specify
Screening,
Diagnostic, Referral Agency
:
□
CTS □ STD clinic
□
Other, specify
Other
Facility
: □ Emergency room
□
Laboratory □ Corrections □ Unknown
□
Other, specify
*Provider Name
*Provider Phone ( )
Specialty
VII. Patient History (respond to all questions) (record all dates as mm/dd/yyyy) □ Pediatric Risk (enter in Comments)
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
Sex with male
□
Yes
□
No
□
Unknown
Sex with female
□
Yes
□
No
□
Unknown
Injected nonprescription drugs
□ Yes □ No □ Unknown
Received clotting factor for hemophilia/coagulation disorder
Specify clotting factor: Date received
/
/
□
Yes
□
No
□
Unknown
HETEROSEXUAL relations with any of the following:
HETEROSEXUAL contact with person who injected drugs
□
Yes
□
No
□
Unknown
HETEROSEXUAL contact with bisexual male
□ Yes □ No □ Unknown
HETEROSEXUAL contact with person with hemophilia/coagulation disorder with documented HIV infection
□
Yes
□
No
□
Unknown
HETEROSEXUAL contact with transfusion recipient with documented HIV infection
□
Yes
□
No
□
Unknown
HETEROSEXUAL contact with transplant recipient with documented HIV infection
□ Yes □ No □ Unknown
HETEROSEXUAL contact with person with documented HIV infection, risk not specified
□
Yes
□
No
□
Unknown
Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments)
□ Yes □ No □ Unknown
First date received
/
/
Last date received
/
/
Received transplant of tissue/organs or artificial insemination
□
Yes
□
No
□
Unknown
Worked in a healthcare or clinical laboratory setting
□ Yes □ No □ Unknown
If occupational exposure is being investigated or considered
as primary mode of exposure, specify occupation and setting:
________________________________________________
Other documented risk (include detail in Comments) __________________________________________________________
□ Yes □ No □ Unknown
VIII. Clinical: Acute HIV Infection and Opportunistic Illnesses (record all dates as mm/dd/yyyy)
Suspect acute HIV infection?
If YES, complete the two items below; enter documented negative HIV test result data in Laboratory Data section,
and enter patient or provider report of previous negative HIV test result in HIV Testing History section
□ Yes □ No □ Unknown
Clinical signs/symptoms consistent with acute retroviral syndrome (e.g., fever, malaise/fatigue, myalgia, pharyngitis, rash,
lymphadenopathy)? Date of sign/symptom onset
/
/
□ Yes □ No □ Unknown
Other evidence suggestive of acute HIV infection? If YES, describe: _________________________________________________
Date of evidence
/
/ _________________________________________________
□ Yes □ No □ Unknown
Opportunistic Illnesses
Diagnosis
Dx Date
Diagnosis
Dx Date
Diagnosis
Dx Date
Candidiasis, bronchi, trachea, or lungs Herpes simplex: chronic ulcers (>1 mo. duration),
bronchitis, pneumonitis, or esophagitis
M. tuberculosis, pulmonary
1
Candidiasis, esophageal Histoplasmosis, disseminated or extrapulmonary M. tuberculosis, disseminated or
extrapulmonary
1
Carcinoma, invasive cervical Isosporiasis, chronic intestinal (>1 mo. duration) Mycobacterium, of other/unidentified species,
disseminated or extrapulmonary
Coccidioidomycosis, disseminated or
extrapulmonary
Kaposi’s sarcoma Pneumocystis pneumonia
Cryptococcosis, extrapulmonary
Lymphoma, Burkitt’s (or equivalent)
Pneumonia, recurrent, in 12 mo. period
Cryptosporidiosis, chronic intestinal (>1 mo.
duration)
Lymphoma, immunoblastic (or equivalent) Progressive multifocal leukoencephalopathy
Cytomegalovirus disease (other than in liver,
spleen, or nodes)
Lymphoma, primary in brain Salmonella septicemia, recurrent
Cytomegalovirus retinitis (with loss of vision) Mycobacterium avium complex or M. kansasii,
disseminated or extrapulmonary
Toxoplasmosis of brain, onset at >1 mo.
of
age
HIV encephalopathy
Wasting syndrome due to HIV
1
If a diagnosis date is entered for either tuberculosis diagnosis above, provide RVCT Case Number:
IX. Laboratory Data (record additional tests and tests not specified below in Comments) (record all dates as mm/dd/yyyy)
HIV Immunoassays
TEST □ HIV-1 IA □ HIV-1/2 IA □ HIV-1/2 Ag/Ab □ HIV-2 IA
Test Brand Name/Manufacturer ____________________________________ Lab Name ______________________________________________________
Facility Name ___________________________________________________ Provider Name __________________________________________________
Result
□
Positive
□
Negative
□
Indeterminate Collection Date / /
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
CDC 50.42A Rev. 01/2023 (Page 3 of 4) —ADULT HIV CONFIDENTIAL CASE REPORT—
IX. Laboratory Data (record additional tests and tests not specified below in Comments) (record all dates as mm/dd/yyyy)
(cont)
TEST □ HIV-1/2 Ag/Ab differentiating immunoassay (differentiates between HIV Ag and HIV Ab)
Test Brand Name/Manufacturer ____________________________________ Lab Name ______________________________________________________
Facility Name ___________________________________________________ Provider Name __________________________________________________
Result Overall: □ Reactive □ Nonreactive Collection Date / /
Analyte results: HIV-1 Ag: □ Reactive □ Nonreactive HIV-1/2 Ab: □ Reactive □ Nonreactive
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
TEST □ HIV-1/2 Ag/Ab and type-differentiating immunoassay (differentiates among HIV-1 Ag, HIV-1 Ab, and HIV-2 Ab)
Test Brand Name/Manufacturer ____________________________________ Lab Name ______________________________________________________
Facility Name ___________________________________________________ Provider Name __________________________________________________
Result
3
Overall interpretation: □ Reactive □ Nonreactive □ Index Value Collection Date / /
Analyte results: HIV-1 Ag: □ Reactive □ Nonreactive □ Not reportable due to high Ab level Index Value
HIV-1 Ab: □ Reactive □ Nonreactive □ Reactive undifferentiated Index Value
HIV-2 Ab: □ Reactive □ Nonreactive □ Reactive undifferentiated Index Value
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
TEST □ HIV-1/2 type-differentiating immunoassay (supplemental) (differentiates between HIV-1 Ab and HIV-2 Ab)
Test Brand Name/Manufacturer ____________________________________ Lab Name ______________________________________________________
Facility Name ___________________________________________________ Provider Name __________________________________________________
Result
4
Overall interpretation: □ HIV positive, untypable □ HIV-1 positive with HIV-2 cross-reactivity □ HIV-2 positive with HIV-1 cross-reactivity
□ HIV negative □ HIV indeterminate □ HIV-1 indeterminate □ HIV-2 indeterminate □ HIV-1 positive □ HIV-2 positive
Analyte results: HIV-1 Ab: □ Positive □ Negative □ Indeterminate Collection Date / /
HIV-2 Ab: □ Positive □ Negative □ Indeterminate
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
TEST □ HIV-1 WB □ HIV-1 IFA □ HIV-2 WB
Test Brand Name/Manufacturer ____________________________________ Lab Name ______________________________________________________
Facility Name ___________________________________________________ Provider Name __________________________________________________
Result □ Positive □ Negative □ Indeterminate Collection Date / /
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
HIV Detection Tests
TEST □ HIV-1/2 RNA NAAT (Qualitative) Lab Name _____________________________________________________
Test Brand Name/Manufacturer ____________________________________ Provider Name _________________________________________________
Facility Name ___________________________________________________ Collection Date / /
Result □ HIV-1 □ HIV-2 □ Both (HIV-1 and HIV-2) □ HIV, not differentiated (HIV-1 or HIV-2) □ Neither (negative)
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
TEST □ HIV-1 RNA NAAT (Qualitative and Quantitative)
Test Brand Name/Manufacturer Lab Name
Facility Name Provider Name
Result Qualitative: □ Reactive □ Nonreactive Collection Date / /
Analyte results: HIV-1 Quantitative: □ Detectable above limit □ Detectable within limits □ Detectable below limit
Copies/mL ____________________ Log ______________
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
TEST □ HIV-1 RNA/DNA NAAT (Qualitative) □ HIV-1 culture □ HIV-2 RNA/DNA NAAT (Qualitative) □ HIV-2 culture
Test Brand Name/Manufacturer ____________________________________ Lab Name ______________________________________________________
Facility Name ___________________________________________________ Provider Name __________________________________________________
Result □ Positive □ Negative □ Indeterminate Collection Date / /
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
TEST □ HIV-1 RNA/DNA NAAT (Quantitative) □ HIV-2 RNA/DNA NAAT (Quantitative)
Test Brand Name/Manufacturer ____________________________________ Lab Name ______________________________________________________
Facility Name ___________________________________________________ Provider Name __________________________________________________
Result □ Detectable above limit □ Detectable within limits □ Detectable below limit □ Not detected Copies/mL _________________ Log ____________
Collection Date / /
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
Drug Resistance Tests (Genotypic)
TEST □ HIV-1 Genotype (Unspecified) Test Brand Name/Manufacturer ____________________________________
Lab Name ______________________________________________________ Facility Name ___________________________________________________
Provider Name __________________________________________________ Collection Date / /
Immunologic Tests (CD4 count and percentage)
CD4 count cells/µL CD4 percentage % Collection Date / /
Test Brand Name/Manufacturer ____________________________________ Lab Name ______________________________________________________
Facility Name ___________________________________________________ Provider Name _________________________________________________
Documentation of Tests
Did documented laboratory test results meet approved HIV diagnostic algorithm criteria? □ Yes □ No □ Unknown
If YES, provide specimen collection date of earliest positive test result for this algorithm / /
Complete the above only if none of the following were positive for HIV-1: Western blot, IFA, culture, quantitative NAAT (RNA or DNA), qualitative NAAT (RNA or
DNA), HIV-1/2 type-differentiating immunoassay (supplemental test), stand-alone p24 antigen, or nucleotide sequence.
Is earliest evidence of HIV infection diagnosis documented by a physician rather than by laboratory test results? □ Yes □ No □ Unknown
If YES, provide date of diagnosis by physician / /
Date of last documented negative HIV test result (before HIV diagnosis date)
/
/
Specify type of test: _____________________________________________
Testing Option (if applicable) □ Point-of-care test by provider □ Self-test, result directly observed by a provider
2
□ Lab test, self-collected sample
2
Results not directly observed by a provider should be recorded in HIV Testing History.
3
Complete the overall interpretation and the analyte results.
4
Always complete the overall interpretation. Complete the analyte results when available.
CDC 50.42A Rev. 01/2023 (Page 4 of 4) —ADULT HIV CONFIDENTIAL CASE REPORT—
X. Treatment/Services Referrals (record all dates as mm/dd/yyyy)
Has this patient been informed of his/her HIV infection?
□ Yes □ No □ Unknown
This patient’s partners will be notified about their HIV exposure and counseled by
□ 1-Health dept □ 2-Physician/Provider □ 3-Patient □ 9-Unknown
Evidence of receipt of HIV medical care other than laboratory test result (select one; record additional evidence in Comments)
□ 1-Yes, documented □ 2-Yes, client self-report, only Date of medical visit or prescription
/
/
For Female Patient
This patient is receiving or has been referred for gynecological or
obstetrical services
□
Yes
□
No
□
Unknown
Is this patient currently pregnant?
□ Yes □ No □ Unknown
Has this patient delivered live-born infants?
□ Yes □ No □ Unknown
For Children of Patient (record most recent birth in these boxes; record additional or multiple births in Comments)
*Child’s Name
Child’s Date of Birth
/
/
Child’s Last Name Soundex
Child’s State Number
Facility Name of Birth
(if child was born at home, enter “home birth”)
*Phone
( )
Facility Type
Inpatient: Outpatient:
Other Facility:
□
Emergency room
□
Hospital
□ Other, specify □ Corrections □ Unknown
□ Other, specify □ Other, specify
*Street Address
*ZIP Code
City
County
State/Country
XI. Antiretroviral Use History (record all dates as mm/dd/yyyy)
Main source of antiretroviral (ARV) use information (select one)
□ Patient interview □ Medical record review □ Provider report □ NHM&E □ Other
Date patient reported information
/
/
Ever taken any ARVs?
☐
Yes
☐
No ☐ Unknown
If yes, reason for ARV use (select all that apply)
□
HIV Tx ARV medications Date began
/
/ Date of last use
/
/
□
PrEP
ARV medications Date began / / Date of last use / /
□
PEP
ARV medications Date began / / Date of last use / /
□
PMTCT
ARV medications Date began / / Date of last use / /
□ HBV Tx ARV medications Date began
/
/ Date of last use
/
/
□ Other (specify reason)
ARV medications Date began
/
/ Date of last use
/
/
XII. HIV Testing History (record all dates as mm/dd/yyyy)
Main source of testing history information (select one)
□ Patient interview □ Medical record review □ Provider report □ NHM&E □ Other
Date patient reported information
/
/
Ever had previous positive HIV test result? □
Yes
□
No
□
Unknown
Date of first positive HIV test result
/
/
Was the first positive test result from a self-test performed by the patient?
□
Yes
□
No
□
Unknown
Ever had a negative HIV test result? □ Yes □ No □ Unknown
Date of last negative HIV test result
(if date is from
a lab test with test type, enter in Lab Data section) / /
Was the last negative test result from a self-test performed by the patient? □ Yes □ No □ Unknown
Number of negative HIV test results within the 24 months before the first positive test result □ Unknown
How many of these negative test results were from self-tests performed by the patient? □ Unknown
XIII. Comments
XIV. *Local/Optional Fields
This report to CDC is authorized by law (Sections 304 and 306 of the Public Health Service Act, 42 USC 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 Health
Service Act (42 USC 242m).