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Massachusetts Infant Case Report Form (Neonatal STI)

Massachusetts DPH uses this one-page form for three infant conditions: congenital syphilis, neonatal herpes and ophthalmia neonatorum. A newborn or pediatric clinician meets it after one of these is diagnosed in an infant. The report covers the infant's clinical course, birth history and the mother's prenatal care, STD testing and treatment before delivery, and is sent to DPH by confidential fax.

Who completes it

The treating clinician or the testing agency completes the whole form, with boxes to mark the treating clinician as the same as the testing agency. Maternal details come from the mother's records; the family completes no part.

Submitting and payment

How to submit it
Fax the completed form to Massachusetts DPH on the confidential fax line printed at the top of the form. DPH posts it as a PDF and a Word file on its Infectious Disease Case Report Forms page.
Who pays
DPH lists no fee or billing code for the report.

Good to know

  • Version 5/16/2018 has three checkboxes at the top, for neonatal herpes, ophthalmia neonatorum and congenital syphilis; mark the condition being reported.
  • Infant clinical items include prophylaxis received, diagnosis date, age at diagnosis in months and days, hospitalization, skin, eye, mucous membrane or CNS involvement, treatment and outcome.
  • The maternal section asks for gravida and para, prenatal care and first visit date, STD tests done before delivery with results, and any STD treatment before delivery.
  • Birth history covers birth setting, estimated gestational age, birth weight, APGAR score and delivery type, including assisted vaginal and elective or non-elective cesarean delivery.

Get the official form

Download the current version from the source each time; forms change without notice.

Infant Case Report Form (Congenital Syphilis, Neonatal Herpes, Ophthalmia Neonatorum)

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Is the Massachusetts Infant Case Report Form available online?

Not yet. DPH has moved many case reports to its online reporting system, but the Neonatal (Infant) Case Report Form is still a paper form, posted as a PDF and a Word document. Gonorrhea and syphilis in older patients are reported through the online forms instead.

Can DPH help notify the mother's partners?

Yes. The form directs clinicians to the DPH Division of STD Prevention to request Partner Notification Services for the patient, and gives a separate DPH number for help with the case or with filling out the form. Both contacts are printed at the top of the page.

What maternal details does the form need?

The mother's name, date of birth, medical record number, address, phone numbers, primary language, country of origin and length of time in the U.S., whether she is homeless or incarcerated, and her prenatal care, STD tests and STD treatment before delivery, each with dates.