Alameda County Social Services Agency

Alameda County Social Services Agency
Department of Children and Family Services
HIV Risk Assessment Checklist
Child’s Name________________________ Birth Date__________ Case #______________
This checklist is to be used by CWW's for every child entering into or active in the Agency’s Foster Care
program to determine if HIV testing is indicated.
The presence of a risk factor in any category listed below should prompt the CWW to seek a physician’s order
for HIV testing of the child.
Check mark and names
Risk factor Child Parent Partner
1 Undocumented history or report of previous positive HIV test
or diagnosis of HIV infection or AIDS in the child, parent or
partner.
Source of information __________________________
2 Drug use by the child:
*History of injection drug use by the child
*Drug related offenses
3 Child has poor health: failure to thrive, chronic infections,
any symptom associated with pediatric AIDS (e.g., swollen
lymph glands, enlarged liver or spleen, chronic cough,
recurrent thrush, chronic diarrhea).
< If this box is
checked child must be
immediately referred
to a physician.
4 Child or teen who is sexually active and whose current or
prior partners are high risk, IDU, or known HIV-infected.
Source of information __________________________
5 Child has blood exposure: Participated in practices involving
shared needles, exchange of blood or blood products, bloodto-blood
contact or unsafe body piercing*.
6 Perinatal HIV exposure:
• born to a known HIV-infected mother
• born to a mother whose HIV status is unknown
7 Parents have high risks, defined as any of the following:
• Sex industry work or survival sex
• Illicit drug use (IV or non-IV)
• Hypodermic needle-sharing
• Sexual partner with an unknown history of risk factors
• Male sexual partner with history of sex with men
8 Child is a victim of sexual abuse which places the child at
risk for HIV.
Child Welfare Worker / Worker Number
________________________________________________ Date ___________________
Child Welfare Supervisor
______________________________________________ __Date ____________________

Instructions for completing the ‘HIV Risk Assessment Checklist’
DO NOT write “unknown” or “did not ask.”
Identify by name the person to whom the information applies, if any, as well as the source of the
information.
The HIV antibody test by itself is not adequate or sufficient to confirm a diagnosis of HIV in babies
under 18 months old. Thus, an infant born to an HIV-positive mother needs a series of special
tests to clarify HIV infection. This testing requires referral to a special HIV clinic, such as Children’s
Hospital & Research Center at Oakland.
Item 5, Unsafe blood practices:
The CDC knows of no instances of HIV transmission through tattooing or body piercing, although
hepatitis B virus has been transmitted during some of these practices. One case of HIV
transmission from acupuncture has been documented. The medical complications for body piercing
appear to be greater than for tattoos. Healing of piercings generally will take weeks, and
sometimes even months, and the pierced tissue could conceivably be abraded (torn or cut) or
inflamed even after healing. Therefore, a theoretical HIV transmission risk does exist if the
unhealed or abraded tissues come into contact with an infected person’s blood or other infectious
body fluid. Additionally, HIV could be transmitted if instruments contaminated with blood are not
sterilized or disinfected between clients.
Item 2, Drug Use by Child:
Intravenous drug use is the direct injection of a drug into a vein. Intramuscular use is injection into
a muscle, and “skin popping” is injection under the skin. Drug use involving the sharing of needles
puts the user at very high risk of HIV infection. Drugs commonly administered intravenously are
heroin, PCP, crack cocaine and crank (amphetamines). Drugs commonly administered
intramuscularly or in the skin include amphetamines and psychedelics, including PCP and LSD.
Young children of parents who deny recent injection drug use but have a history of using heroin,
PCP, cocaine (crack) and amphetamine (crank) must be tested, as current research indicates a
high correlation of use of these drugs with HIV infection, regardless of route of administration.
Revised June 10, 2005