HIV Perinatal

Complete this worksheet for any newborn infant whose mother is known to have an HIV diagnosis before or during the child's birth. Form should be completed within 72 hours of delivery.

Date form completed(MM/DD/YYYY)://
Reporting Facility Name:
Reporting Facility Address:	City:
State:	Zip Code:
Person Completing Form:
Reporting Phone Number:	Email Address:

Newborn History

Delivery Location if Different from Reporting Facility:
Date of Delivery: //	Method of Delivery:
Did baby receive HIV testing upon delivery?
Physician's Name (baby):
Baby's First Name:	Baby's Last Name:
Baby's Medical Record #:

Maternal History

Mother' First Name:	Mother' Last Name:
Birth Mother's DOB //	Mother's Medical Record #:

Was mother's HIV status known before or during delivery? Yes No Unknown

Additional Notes:

For any questions related to this form, please contact Crystal Fuller at Crystal.Fuller@dph.ga.gov

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