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HIV/AIDS Confidential Case Reporting Forms

Indiana Department of Health Confidential Case Report Forms

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 North Meridian Street, 6-C
Indianapolis, IN 46204

SF51201 Adult HIV/AIDS Confidential Case Report (>13 years of age at the time of diagnosis)

SF51202 Pediatric HIV/AIDS Confidential Case Report (<13 years of age at the time of diagnosis)

SF54730 Perinatal Exposure Confidential Case Report (for children born to mothers with HIV/AIDS diagnosis)

Instructions for completing the Indiana HIV Case Report forms

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

Additional resources regarding reporting: