the instructions for Form 1040A, lines 42a and 42b, or Form 1040, lines 66a and 66b, unless the child was born and died in 2017. If your child was born and died in 2017 and did not have an SSN, enter “Died” on this line and attach a copy of the child’s birth certificate, death certificate, or hospital medical records showing a live birth. INSTRUCTIONS FOR COMPLETION OF THE MICHIGAN PEDIATRIC CONFIDENTIAL HIV/AIDS CASE REPORT FORM (PCRF) DCH FORM #1402 April 2016 The Michigan Pediatric HIV/AIDS Confidential Case Report Form (PCRF) DCH Form #1402 is Michigan’s version of the Centers for Disease Control (CDC) Pediatric HIV/AIDS Confidential Case Report Form #50.42B.

different format (e.g., line list, telephone notification) record the date of initial contact with CDC and NOT the date the form is completed. 5. Case name: Write the last name, first name, middle name or initial, suffix, and nickname or alias (if any) of the case. 6. Address: Write the street number and apartment number, the city, county, INSTRUCTIONS FOR COMPLETION OF THE MICHIGAN PEDIATRIC CONFIDENTIAL HIV/AIDS CASE REPORT FORM (PCRF) DCH FORM #1402 April 2016 The Michigan Pediatric HIV/AIDS Confidential Case Report Form (PCRF) DCH Form #1402 is Michigan’s version of the Centers for Disease Control (CDC) Pediatric HIV/AIDS Confidential Case Report Form #50.42B.