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Case Reporting Information for Healthcare Providers

The Division of Public Health, Department of Health and Human Services, is authorized by law (N.C. G.S. § 130A-134 through 130A-143 External link) to collect reports of cases of certain communicable diseases. North Carolina General Statute § 130A-135 External link requires licensed physicians to report cases and suspected cases of reportable communicable diseases and conditions in persons who have consulted them professionally.

Cases of HIV infection and AIDS should be reported on the communicable disease report card (DHHS 2124) (Word, 46KB) and the surveillance form appropriate for the age of the patient: adult (CDC Form 50.42A) (PDF, 289KB) or pediatric (CDC Form 50.42B) (PDF, 289KB). Physicians should forward case reports to the local health department in which they are consulted. Find local health departments by county. External link


Q. Which local health department should receive the morbidity reports?

A. Reports should be sent to the local health department of the county in which the clinician/physician is consulted. If the patient resides in another county, the local health department will forward the report to the health department of the county of residence for the patient. Local health department then forward the information to the HIV/STD Prevention & Care Program in Raleigh. If the patient resides in another state, state officials will forward the report information to the other state. Find local health departments by county. External link

Q. Do I have to report a new patient that moved to this area and says that he (she) was already reported?

A. Yes. Physicians who are consulted professionally by patient with a confirmed diagnosis must report the case regardless of whether the case has been previously reported. The report is treated as an update and the information is helpful in properly categorizing the epidemic.

Q. The patient says that he (she) was tested anonymously much earlier and had a positive result. Do I record this information as the "first test date"?

A. No. Only documented (through consultation with the previous provider) test results should be entered as the first test date. Other information should be included in comments. Also the residency at diagnosis should reflected the residency of the patient when he or she was first diagnosed or documented.

Q. Should I report a baby born to an HIV-infected mother?

A. Yes, perinatally exposed infants should be reported on confidential case report form CDC 50.42B (PDF, 289KB). Although not required unless HIV infection is confirmed, current rules allow the reporting of perinatally exposed infants and physicians are strongly encouraged to do so. If the child is determined later to be not infected, another report should be completed with the confirmatory (not infected) test results. Likewise, if the child is determined to be infected, another report should be completed with the confirmatory (infected) test results.

Q. Who can I contact for more information about reporting?

A. Contact the closest HIV/STD Prevention & Care Regional Offices (PDF, 166KB) and ask for the "surveillance coordinator".

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