Connecticut providers report a new HIV infection or AIDS diagnosis in patients 13 or older on this 2-page confidential form from the DPH HIV Surveillance Program. It collects patient and provider information, demographics, facility of diagnosis, risk factor history, antiretroviral use including PrEP and PEP, HIV testing history, laboratory data, CD4 counts and AIDS indicator diseases.
The diagnosing or treating provider, or the person reporting for the facility, completes the whole form and records the date completed.
Download the current version from the source each time; forms change without notice.
Adult HIV Confidential Case Report Form
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No. Connecticut's reportable disease list marks HIV infection, acute HIV infection and AIDS as reported only to DPH. Use this HIV case report form rather than the general PD-23, and send it to the DPH HIV Surveillance Program.
It asks for HIV antibody tests (non-type-differentiating and type-differentiating), quantitative and qualitative HIV detection tests such as RNA viral load or NAAT, collection dates, genotype, and CD4 counts closest to current status and the first below 200 or 14%.