Online non-emergency report of suspected child abuse or neglect by a mandated reporter.
- Completed by
- Mandated reporter (physician, nurse, other health practitioner)
- Issued by
- DC Child and Family Services Agency
- Format
- Online only
- Language
- English
DC Notifiable Disease and Pregnancy Report Form
DC Health's HAHSTA uses this one-page form to learn about pregnancies in patients diagnosed with HIV, hepatitis B or syphilis. A prenatal care provider completes it once a pregnant patient has one of these diagnoses, so HAHSTA can follow linkage to care, treatment and the planned delivery hospital. Cases are reported by name, with copies of all lab reports attached.
Who completes it
The prenatal care provider or facility completes the whole form, including provider and delivery hospital details, and names the person completing it if that is not the provider. The office-use state number is left for HAHSTA.
Submitting and payment
- How to submit it
- Fax the completed form, with copies of all lab reports, to HAHSTA's confidential fax line printed at the bottom of the form.
- Who pays
- DC Health lists no fee or payment for this report.
Good to know
- Check one or more diagnoses (HIV, hepatitis B, syphilis) and attach every related lab report, since the form has no fields for lab results.
- Linkage to care asks whether the patient is in obstetrical and specialist care, the EDD, the date of diagnosis, and current treatment with medication names.
- The form also asks about insurance, housing, income, incarceration history, and concerns such as medication adherence, substance use, mental health, transportation and food assistance.
- DC Health links this file as the Pregnancy and HIV Reporting Form, and pairs it with a postnatal hepatitis B referral form for exposed infants.
Get the official form
Download the current version from the source each time; forms change without notice.
Notifiable Disease and Pregnancy Report Form
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
When is the DC Notifiable Disease and Pregnancy Report Form used?
When a patient diagnosed with HIV, hepatitis B or syphilis is pregnant. The form states that cases of pregnancy in women with certain notifiable diseases are reportable to DC Health's HIV/AIDS, Hepatitis, STD, and TB Administration, and that all cases are reported by name. Copies of all lab reports go with it.
Can the DC pregnancy report form be filled in electronically?
Yes. DC Health posts it as a one-page fillable PDF, a 2024 revision, so it can be typed, printed and faxed to HAHSTA's confidential line. A provider email and fax number are requested in the provider section, along with the delivery hospital if it differs from the reporting facility.