HIV/AIDS Case Report 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.
