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
INFANT 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.
NEONATAL HERPES
OPHTHALMIA NEONATORUM
CONGENITAL SYPHILIS
INFANT INFORMATION
Last First DOB:___/____/____ Med Rec #:____________________
Name:___________________________________Name:__________________________________ Middle Initial: _____Social Security #:_______________
Street Address:
Gender:
Homeless
Male Female
City: Zip:
Ethnicity:
Hispanic/Latino Non-Hispanic Latino Unknown
White
Black
Asian Native Hawaiian/Pacific Islander American Indian/Alaskan Native Other__________ Unknown
Yes
No Unknown
TESTING AGENCY INFORMATION
Provider Name:__________________________________ Facility:________________________________________ Phone #:_________________________
Address:_____________________________________ City:_____________________ Zip:_______________ Fax:__________________
TREATING CLINICIAN INFORMATION (If different from testing agency):
Clinician Name:______________________________ Facility:______________________________________________ Phone #:______________________
Address:____________________________________ City:____________________________________ Zip:______________ Fax:_________________
ADMINISTRATIVE INFORMATION Date Form Completed: _____/______/______
Name/Contact Information of person completing report (if not treating clinician):____________________________________________________________
INFANT CLINICAL INFORMATION
Prophylaxis received:
If yes, name of medication: _____________________________________
Date given: _____/______/______
Diagnosis Date: _____/______/______
Age at diagnosis: ______Months ______Days
Was patient hospitalized for this diagnosis?
If yes, hospital address: ________________________________________
Comorbidities: ________________________________________________
Outcome:
Date of death: ______/______/_______
Race: (check all that apply)
Same as testing agency
Same as treating clinician
MATERNAL INFORMATION
Last First DOB:___/____/____ Med Rec #:____________________
Name:___________________________________Name:__________________________________ Middle Initial: _____Social Security #:_______________
Street Address:
Homeless Incarcerated
Gravida: _________ Para: ___________
Prenatal care received?
If yes, date of first prenatal visit: _____/______/_______
Total number of prenatal visits: ____________________
Was mother tested for any STD prior to delivery?
Yes No
BIRTH HISTORY
Birth settting:
Estimated Gestational Age: _______ weeks ______days Birth weight: ________grams APGAR score: _________
Ruptured membranes: ________ hours prior to delivery. Artificially ruptured?
Mode of delivery: Assisted vaginal delivery:
Died Recovered Unknown
Did the patient have symptoms?
If symptomatic, what was the patient diagnosed with? (check all that apply)
Treatment Start Date: _____/______/________
Treatment:_____________________________________________________
Skin infection
Eye infection
Mucous membrane infection
CNS involvement
Disseminated disease
Hospital: _________________________ Discharge date: ___/___/___Home
Yes No Unknown
Lesions
same as above
Cell Phone #: ____________________ Home Phone #: ________________
Primary language spoken: ________________________________________
Mother's country of origin:________________________________________
Length of time in the U.S.:_________________________________________
MATERNAL CLINICAL HISTORY
Yes No
Unknown
Unknown
List STD tests performed on mother prior to delivery:
Test: _____________________________ Result:_______________________
Test: _____________________________ Result: ______________________
Test: _____________________________ Result: ______________________
Did mother receive treatment for any STD prior to delivery?
If yes, list here:
Test: _______________________ Treatment date: _____/______/_______
Test: _______________________ Treatment date: _____/______/_______
Test: _______________________ Treatment date: _____/______/_______
Yes No Unknown
Other, describe: ___________________
NSVD with forcepsElective caesarean Non-elective caesarean
Yes No Unknown
with vaccuum
Yes No Unk
Sepsis
Pneumonia
Other: _________________________________________________
