Massachusetts Department of Public Health
Bureau of Infectious Disease and Laboratory Sciences
Office of Integrated Surveillance and Informatics Services
305 South Street, Jamaica Plain, MA 02130
Phone: 617-983-6801 Confidential Fax: 617-983-6813
To request Partner Notification Services for your patient, please call the Division of STD Prevention at (617) 983-6940
CASE REPORT FORM
Version 5/16/2018
For assistance filling out this form, call (617) 983-6801.
If you need help with this case, please call (617) 983-6940.
CHANCROID
GRANULOMA INGUINALE PID (AGENT UNKNOWN)
LYMPHOGRANULOMA VENEREUM (LGV)
PATIENT INFORMATION
Last First DOB:___/____/____ Med Rec #:____________________
Name:___________________________________Name:__________________________________ Middle Initial: _____Social Security #:_______________
Street Address:
Gender:
Homeless
Incarcerated
Male Female Transgender Unknown
City: Zip:
Ethnicity:
Hispanic/Latino Non-Hispanic Latino Unknown
White
Black
Asian
Native Hawaiian/Pacific Islander American Indian/Alaskan Native
Other(specify):__________________________ UnknownEnglish Other(specify):_________
If asymptomatic, why was the patient tested? Check all that apply.
Yes
No Unknown
Yes No Unknown
Not applicable
Lab test, if performed (e.g. biopsy, culture, serology):
1. ______________________________________________ →
2. ______________________________________________ →
3. ______________________________________________ →
Result:
1. ________________________________
2. ________________________________
3. ________________________________
Does the patient have sex with:
Has the patient exchanged money for sex and/or drugs?
Has the patient had sex while intoxicated and/or high?
Has the patient travelled out of the state in the last year?
Has the patient been incarcerated in the last 60 days?
Other risk factors:_____________________________________________________________________________________________
Treatment Start Date:__ /___/___ Treatment: ____________________________________________________________________
TESTING AGENCY INFORMATION
Provider Name:__________________________________ Facility:________________________________________ Phone #:_________________________
Address:_____________________________________ City:_____________________ Zip:_______________ Fax:__________________
Testing Setting:
Drug Treatment Facility
HIV Counseling, Testing, and Referral Site
Blood Bank
TREATING CLINICIAN INFORMATION (If different from testing agency):
Clinician Name:______________________________ Facility:______________________________________________ Phone #:______________________
Address:____________________________________ City:____________________________________ Zip:______________ Fax:_________________
Clinician Practice Setting:
Private Practice or HMO
Community Health Center
ADMINISTRATIVE INFORMATION Date Form Completed: _____/______/______
Name/Contact Information of person completing report (if not treating clinician):____________________________________________________________
Hospital-based Clinic
STD, HIV, or Family Planning Clinic
ER or Urgent Care
School-based Clinic including College/University
Military/VA/Job Corps Clinic
Correctional Institution
Other(specify):__________________
Mental Health Services Site
Other(specify):______________________________________________________________________________
Private Practice or HMO
Community Health Center
Hospital-based Clinic
STD, HIV or Family Planning Clinic
ER or Urgent Care
School-based Clinic including College/University
Military/VA/Job Corps Clinic
Correctional Institution
Pregnant:
Unknown
Unknown
Unknown
Unknown
Unknown
Men Women Both
Yes No
Yes No
Yes (specify):________________________________ No
Yes No
Cell Phone #: Home Phone #:
Primary Language Spoken:
CLINICAL INFORMATION Diagnosis Date:_____/______/______
Did the patient have any symptoms?
If yes, what was the patient diagnosed with? ______________________
____________________________________________________________
Race: (check all that apply)
Same as testing agency
Same as treating clinician
Specimen site:
1. _____________________________ →
2. _____________________________ →
3. _____________________________ →
Contact to STD Patient request Other ____________
