Wisconsin HIV Infection and AIDS Case Report, F-44338



DEPARTMENT OF HEALTH SERVICES (DHS)Division of Public HealthF-44338 (12/2023)STATE OF WISCONSINWis. Stat. § 252.05 requires that this information be reported.WISCONSIN HIV CASE REPORT(Patients >13 Years of Age at Time of Diagnosis)Diagnosis Status: FORMCHECKBOX Acute FORMCHECKBOX HIV FORMCHECKBOX Stage 3 (AIDS)DHS State Number FORMTEXT ?????(DHS use only)PATIENT IDENTIFICATIONPatient’s Legal NameFirst NameMiddle NameLast Name FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Also Known As (e.g., alias, married, maiden)First NameMiddle NameLast Name FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Address Type FORMCHECKBOX Residential FORMCHECKBOX Correctional Facility FORMCHECKBOX Military Base FORMCHECKBOX Foster Home FORMCHECKBOX Homeless FORMCHECKBOX Postal FORMCHECKBOX Shelter FORMCHECKBOX Temporary FORMCHECKBOX Other FORMTEXT ?????Current Street AddressIf current address is a facility (e.g., corrections, nursing home, shelter), provide name FORMTEXT ????? FORMTEXT ?????CityCountyState/CountryZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Phone – PrimaryPhone – SecondarySocial Security Number*Vital StatusDate of Death FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Alive FORMCHECKBOX Dead FORMTEXT ?????PATIENT DEMOGRAPHICS (Record all dates as mm/dd/yyyy.)Date of BirthCountry of BirthPreferred Language FORMTEXT ????? FORMCHECKBOX US FORMCHECKBOX Other – specify: FORMTEXT ????? FORMTEXT ?????Sex Assigned at BirthCurrent Gender IdentityDate Identified: FORMTEXT ????? FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Unknown FORMCHECKBOX Cisgender Man FORMCHECKBOX Transgender Man FORMCHECKBOX Unknown FORMCHECKBOX Cisgender Woman FORMCHECKBOX Transgender Woman FORMCHECKBOX Additional Gender Identity – specify: FORMTEXT ?????Ethnicity FORMCHECKBOX Hispanic/Latino FORMCHECKBOX Not Hispanic/Latino FORMCHECKBOX UnknownRace(Check all that apply) FORMCHECKBOX American Indian/Alaska Native FORMCHECKBOX Black/African American FORMCHECKBOX White FORMCHECKBOX Asian FORMCHECKBOX Native Hawaiian/Pacific Islander FORMCHECKBOX UnknownSexual Orientation FORMCHECKBOX Straight or heterosexual FORMCHECKBOX Lesbian or gay FORMCHECKBOX Bisexual FORMCHECKBOX Unknown FORMCHECKBOX Additional sexual orientation – specify: FORMTEXT ?????Date Identified: FORMTEXT ?????For Person of Childbearing PotentialThis patient is receiving or has been referred for gynecological and/or obstetrical (OBGYN) services: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIs this patient currently pregnant?Has this patient delivered live-born infants? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf currently pregnant, estimated date of delivery:Has this patient been referred for prenatal care? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????Date of referral: FORMTEXT ????? FORMCHECKBOX OBGYN FORMCHECKBOX WI HIV Primary Care Support NetworkRESIDENCE AT DIAGNOSISStreet Address at HIV DiagnosisCityCountyState/CountryZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Check if same as current addressStreet Address at Stage 3 (AIDS) DiagnosisCityCountyState/CountryZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Check if same as current addressFACILITY OF DIAGNOSISFacility NameStreet Address FORMTEXT ????? FORMTEXT ?????CityCountyState/CountryZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FacilityTypeInpatient FORMCHECKBOX Hospital FORMCHECKBOX Other (specify) FORMTEXT ?????OutpatientOther Facility FORMCHECKBOX Private Physician’s Office FORMCHECKBOX Adult HIV Clinic FORMCHECKBOX VAMC FORMCHECKBOX Other – specify: FORMTEXT ????? FORMCHECKBOX HIV Testing Site FORMCHECKBOX STD Clinic FORMCHECKBOX Blood/Plasma Center FORMCHECKBOX Family Planning ClinicA# FORMTEXT ????? FORMCHECKBOX Emergency Room FORMCHECKBOX Corrections FORMCHECKBOX Other – specify: FORMTEXT ?????Name of Provider That Ordered HIV Diagnostic TestsSpecialtyPhone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FACILITY PROVIDING INFORMATION FORMCHECKBOX Check if SAME as Facility of Diagnosis and go to Person Providing InformationFacility NameStreet Address FORMTEXT ????? FORMTEXT ?????CityCountyState/CountryZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FacilityTypeInpatient FORMCHECKBOX Hospital FORMCHECKBOX Other – specify FORMTEXT ?????OutpatientOther Facility FORMCHECKBOX Private Physician’s Office FORMCHECKBOX Adult HIV Clinic FORMCHECKBOX VAMC FORMCHECKBOX Other – specify FORMTEXT ????? FORMCHECKBOX HIV Testing Site FORMCHECKBOX STD Clinic FORMCHECKBOX Blood/Plasma Center FORMCHECKBOX Family Planning Clinic A# FORMTEXT ????? FORMCHECKBOX Emergency Room FORMCHECKBOX Corrections FORMCHECKBOX Other – specify FORMTEXT ?????PERSON PROVIDING INFORMATIONDate Form Completed (mm/dd/yyyy)Person Completing FormPhone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PATIENT HISTORY (Check all that apply. Record additional risk information in Comments Section.) This patient had:Sex with person assigned male at birth FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownSex with person assigned female at birth FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownInjected nonprescription drugs or shared injection equipment FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHeterosexual contact with person who injects drugs FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHeterosexual contact with bisexual person assigned male at birth (for patient assigned female at birth only) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHeterosexual contact with person living with HIV, risk not specified FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownReceived transplant/transfusion/clotting disorder FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownWorked in a healthcare or clinical laboratory setting FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownPerinatally acquired HIV FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownOPPORTUNISTIC DIAGNOSES (Record additional diagnoses in Comments Section. Click here for common opportunistic diagnoses.)Diagnosis Date (mm/dd/yyyy)Candidiasis, esophageal FORMTEXT ?????Cytomegalovirus disease (other than in liver, spleen, or nodes) FORMTEXT ?????Kaposi’s sarcoma FORMTEXT ?????Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary FORMTEXT ?????Pneumocystis pneumonia FORMTEXT ?????Wasting syndrome due to HIV FORMTEXT ?????LABORATORY DATA (Record dates as mm/dd/yyyy and additional tests and POC rapid HIV test types in Comments Section.)HIV Screening Test at Diagnosis(Non-Differentiating/Differentiating)Immunologic Tests (CD4)PosNegIndCollection Date First CD4 <200 ?L or <14%:Collection DateHIV-1 EIA FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Count FORMTEXT ?????Percent FORMTEXT ?????% FORMTEXT ?????HIV-1/2 EIA FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Most Recent CD4:HIV-1/2 Ag/Ab FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Count FORMTEXT ?????Percent FORMTEXT ?????% FORMTEXT ?????HIV-1 WB/IFA FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Resistance TestsHIV-2 EIA FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Collection DateHIV-2 WB FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Genotyping FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????Point-of-Care Rapid HIV Test 1 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Past HIV TestingPoint-of-Care Rapid HIV Test 2 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Has this person ever had a negative HIV test?HIV Antibody Test at Diagnosis (Differentiating/Supplemental) FORMCHECKBOX Yes, medical record Date of test: FORMTEXT ????? Test type: FORMTEXT ?????PosNegIndCollection Date FORMCHECKBOX Yes, self-report Date of test: FORMTEXT ????? Test type: FORMTEXT ?????HIV-1 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX No HIV-2 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????HIV Detection/Viral Load Tests (Quantitative)Has this patient ever had a positive HIV test?Copies/mlCollection Date FORMCHECKBOX Yes, medical record Date of test: FORMTEXT ????? Test type: FORMTEXT ?????First HIV-1 RNA/DNA NAAT FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes, self-report Date of test: FORMTEXT ????? Test type: FORMTEXT ?????Most recent HIV-1 RNA/DNA NAAT FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No HIV-2 RNA NAAT FORMTEXT ????? FORMTEXT ?????HIV Detection Tests (Qualitative)Collection DateHIV-1 RNA/DNA NAAT (Nucleic Acid Amplification Test) FORMCHECKBOX Detectable FORMCHECKBOX Undetectable FORMTEXT ?????HIV-2 RNA NAAT (Nucleic Acid Amplification Test) FORMCHECKBOX Detectable FORMCHECKBOX Undetectable FORMTEXT ?????HIV 1-2 Dual NAAT FORMCHECKBOX HIV-1 FORMCHECKBOX HIV-2 FORMCHECKBOX Both FORMCHECKBOX Undetectable FORMTEXT ?????TREATMENT HISTORYHas patient ever taken any antiretroviral medications (ARVs)?Has this patient been informed of their HIV diagnosis? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown Date: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownReason for ARV use (select all that apply)ARVs ever taken (select all that apply) Click for full ARV list FORMCHECKBOX HIV treatment FORMCHECKBOX Pre-exposure prophylaxis (PrEP) FORMCHECKBOX Post-exposure prophylaxis (PEP) FORMCHECKBOX Other reasons FORMCHECKBOX Atripula FORMCHECKBOX Biktarvy FORMCHECKBOX Cabenuva FORMCHECKBOX Descovy FORMCHECKBOX Genvoya FORMCHECKBOX Juluca FORMCHECKBOX Odefsey FORMCHECKBOX Prezista FORMCHECKBOX Symtuza FORMCHECKBOX Tivicay FORMCHECKBOX Triumeq FORMCHECKBOX Truvada FORMCHECKBOX Other: FORMTEXT ?????What is the earliest date any ARVs were taken (including prior to diagnosis)? FORMTEXT ?????What is the date of last ARV use? FORMTEXT ?????COMMENTS SECTION FORMTEXT ?????502457715265If you have any questions, call 608-267-5287 or email DHSHIVSurveillance@dhs.. 00If you have any questions, call 608-267-5287 or email DHSHIVSurveillance@dhs.. Complete and submit the case report form by one of the following (preferred in bold):Submit electronically via Wisconsin Electronic Disease Surveillance System (WEDSS)Fax to 608-720-3548 Call 608-267-5287 to leave a message (HIV Surveillance staff will call back)Send the report form in an envelope marked “CONFIDENTIAL” to: Scott Stokes, Division of Public Health, PO Box 2659, MADISON, WI 53701–2659Confirmed and suspect cases of HIV, including Stage 3 (AIDS), are required to be reported to the Division of Public Health within 72 hours of identification per Wis. Stat. § 252.05. Information provided is confidential as required per Wis. Stat. § 252.15.*Disclosure of Social Security Number is voluntary. The Social Security Number and other information on this form are used for surveillance, control, and prevention of HIV infections. The information is collected with a guarantee that it will be held in confidence, will be used only for the purposes stated and will not otherwise be disclosed or released without the consent of the individual. ................
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