Child’s Soundex Hospital of Birth / FACILITY SETTING / LABORATORY DATA / If HIV laboratory / Facility Name Yes No Unk / FACILITY OF DIAGNOSIS V / /
IndustryTerm
related medical services / obstetrical services / social work/support services / abuse treatment services / therapy for HIV / /
MedicalCondition
HIV infection / NA Pneumonia / Hemophilia A / HIV / NA Salmonella septicemia / Wasting syndrome / NA Isosporiasis / esophagitis / bronchitis / Pneumocystis carinii pneumonia / chronic / Hemophilia B / Histoplasmosis / Herpes / Cryptosporidiosis / Carcinoma / NA Toxoplasmosis / Cytomegalovirus retinitis / pulmonary / Cytomegalovirus disease / lymphadenopathy / disorder / Kaposi’s sarcoma / Coccidioidomycosis / AIDS / HIV/AIDS / MS / Cryptococcosis / pneumonitis / NA M. Tuberculosis / IV notifiable diseases / hemophilia / syndrome / Tuberculosis / /
MedicalTreatment
Anti-retroviral therapy / counseling / /
Organization
National Institute of Health / Unknown government / Dept of Health / Child’s Soundex Hospital of Birth / state health department / An / Department of Health / Centers for Disease Control and Prevention / / /
Position
REPRESENTATIVE Public reporting burden / Project Clearance Officer / physician / manager of a clinic / Private / Regional HIV/AIDS Surveillance Coordinator / superintendent / /
INSTRUCTIONS FOR COMPLETING FORMS PH-3273 FOR ADULT HIV/AIDS CASE REPORT AND PH-3274 FOR PEDIATRIC HIV/AIDS CASE REPORT Please report persons age 13 and older at diagnosis of HIV and/or AIDS on form PH[removed]Persons age