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CDC 50.42A Adult HIV Confidential Case Report Form

CDC 50.42A is the standard form health departments use to collect adult HIV case reports for the National HIV Surveillance System. A clinician meets it after diagnosing HIV or stage 3 (AIDS) in a patient aged 13 or older at diagnosis. The health department enters the report into eHARS; fields marked with an asterisk, such as name and address, stay local and are not transmitted to CDC.

Who completes it

The diagnosing or treating provider or facility completes section I and sections III through XIII, covering facility, demographics, risk history, clinical and laboratory data, treatment, antiretroviral use and HIV testing history. Section II is for health department use only.

Submitting and payment

How to submit it
Send it confidentially to the HIV surveillance unit of your state or local health department, never to CDC; Minnesota, for example, takes it by secure fax or mail marked confidential and forbids email. Florida asks for it at the county health department within two weeks of diagnosis.
Who pays
CDC and the health departments that distribute the form list no fee or payment for completing it.

Good to know

  • Section X asks whether the patient has been told of the HIV diagnosis and who will notify partners: the health department, the provider or the patient.
  • Section X also records the patient's most recent birth, with the child's name, date of birth and birth facility, and more births in the comments.
  • Several states use their own versions, such as Texas DSHS 13-13674 and Washington DOH 150-002, so use the form your health department distributes.
  • Children under 13 at diagnosis or perinatal exposure are reported on the companion Pediatric HIV Confidential Case Report Form, CDC 50.42B.

Get the official form

Download the current version from the source each time; forms change without notice.

Adult HIV Confidential Case Report Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Can I email the adult HIV case report form?

No. The form goes confidentially to the state or local health department, not by email and not to CDC. Minnesota's instructions, for example, say never to email it under any circumstances and ask providers to mark it confidential and send it by secure fax or mail to the HIV Surveillance Unit.

Is reporting on CDC 50.42A mandatory?

The form states that response is voluntary for federal government purposes but may be mandatory under state and local statutes, and state rules such as Florida's require providers to report HIV cases on it. Identifying information in CDC's National HIV Surveillance System is held in confidence under Section 308(d) of the Public Health Service Act.

What age range does CDC 50.42A cover?

Patients who were 13 or older at the time of HIV diagnosis. Children under 13 at diagnosis, and infants with perinatal HIV exposure, are reported on CDC 50.42B, the pediatric form. The current adult form is revision 01/2023, approved under OMB number 0920-0573.