IN.gov - Skip Navigation

Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.

Amber Alert
Amber Alert - TEST

HIV/AIDS in Indiana > Clinical Data and Research > HIV/AIDS Confidential Case Reporting Forms HIV/AIDS Confidential Case Reporting Forms

Indiana State Department of Health Confidential Case Report Forms

NOTE: DO NOT FAX Case Report Forms; completed Case Report Forms should be mailed to:

Office of Clinical Data and Research
Indiana State Department of Health
2 N. Meridian St., 6-C
Indianapolis, IN 46204

SF51201 ADULT HIV/AIDS CONFIDENTIAL CASE REPORT (>13 years of age at time of diagnosis)

SF51202 PEDIATRIC HIV/AIDS CONFIDENTIAL CASE REPORT  (<13 years of age at time of diagnosis)

SF54730 PERINATAL EXPOSURE CONFIDENTIAL REPORT FOR CHILDREN BORN TO MOTHERS WITH HIV INFECTION

Additional resources regarding reporting:

  • Communicable Disease Rule (PDF Format)
  • Link to Instructions for filling out an Adult Confidential Case Report form, and highlighting the new areas of the form:

Microsoft Powerpoint Presentation

OR

PDF Version

Stay Connected

You are leaving the IN.gov website. By clicking OK, you will be taken to a website that is not affiliated with the State of Indiana and may have different privacy and security policies. The State of Indiana is not responsible for, and does not endorse, guarantee, or monitor content, availability, viewpoints, products, or services that are offered or expressed on this non IN.gov portal website.