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

Instructions for completing the Indiana HIV Case Report form: (PDF Format)

These forms may be used any time but they are required on all reports made after January 15, 2013

 

Additional resources regarding reporting: