Michigan medical providers who diagnose or care for HIV in a patient older than 13 complete the DCH-1355 (MDHHS Form 1355) in addition to the lab's electronic reporting. The Bureau of HIV and STI Programs' surveillance unit uses it to record diagnosis, risk history, lab data, Stage 3 (AIDS) illnesses, pregnancy and referrals. The current Word template is revised 3-26.
The medical provider or facility staff completes Sections 2 to 12; Section 1 is for surveillance use only. The patient fills in nothing, though Section 12's testing and treatment history can come from a patient interview.
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Michigan Adult HIV Confidential Case Report Form
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Yes. Michigan's disease reporting guide says HIV lab results are reported electronically or by arrangement with MDHHS, and that the medical provider should also complete the case report form, MDHHS Form 1355, and fax it to the Bureau of HIV & STI Programs Surveillance Unit.
Section 8 asks whether the HIV diagnosis has been confirmed by a clinical care provider when lab tests were not documented, and the date of that documentation. It also asks for the viral load, the CD4 count closest to the current diagnostic status and any genotype.