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Infectious disease case report forms

Case report forms for selected infectious diseases may be found below or may be found on Infectious Disease Case Report Forms (mass.gov).  The latter website contains links to the new online electronic reporting system.  As paper-based forms are converted to electronic forms, this page will be updated.

If you do not see a relevant form on either page, or if you have questions about how to report an infectious disease, please call (617) 983-6801.  If you encounter technical issues when submitting an electronic case report form, please email immediatediseasereporting@mass.gov and sli-bidappsupport-edss@mass.gov.

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E-cigarette/Vaping-Associated Lung Injury (EVALI)

Open PDF file, 139.12 KB,  Vaping Associated Lung Disease Declaration (English, PDF 139.12 KB)
Open DOCX file, 29.99 KB,  Vaping Associated Lung Disease Declaration (Accessible) (English, DOCX 29.99 KB)
Clinical Advisory: Mandatory reporting of possible cases of unexplained vaping-associated pulmonary disease 
Open PDF file, 286.84 KB,  Vaping Associated Severe Pulmonary Disease Report Form (English, PDF 286.84 KB)

Chancroid/LGV/Granuloma Inguinale/PID (Agent Unknown)

Open PDF file, 147.8 KB,  Chancroid-LGV-Granuloma Inguinale PID Case Report Form (English, PDF 147.8 KB)

Chlamydia

Paper case reports of Chlamydia are no longer required.

COVID-19

Breakthrough COVID-19 Cases Resulting in Hospitalization or Death are no longer required to be reported.

Gastrointestinal illness

Please follow the link below to report a known or suspected cluster of gastrointestinal illness in a healthcare setting.

Infectious Disease Case Report Forms (mass.gov) 

Gonorrhea

Please follow the link below to submit a report of Gonorrhea.

Infectious Disease Case Report Forms (mass.gov) 

Hepatitis B

Please follow the link below to submit a report of infants born to hepatitis B infected women or a report of pregnant women with laboratory evidence of hepatitis B infection.

Infectious Disease Case Report Forms (mass.gov) 

HIV/AIDS

Open DOCX file, 51.98 KB,  HIV/AIDS Case Report Form (English, DOCX 51.98 KB)
Open PDF file, 142.71 KB,  HIV/AIDS Case Report Form (English, PDF 142.71 KB)
Open DOCX file, 36.57 KB,  Instructions for completing Adult HIV/AIDS Case report Form (English, DOCX 36.57 KB)

Influenza/Respiratory Illness

Please follow the link below to report any known or suspected clusters of influenza or other respiratory illness in a facility.

Infectious Disease Case Report Forms (mass.gov) 

Neonatal

Open PDF file, 126.87 KB,  Neonatal Case Report Form (English, PDF 126.87 KB)

Use this form to report congenital syphilis, neonatal herpes, or ophthalmia neonatorum.

Syphilis

Please follow the link below to submit a report of all stage syphilis infections.

Infectious Disease Case Report Forms 

Tuberculosis

Please follow the link below to report any positive test for TB (IGRA or TST) or to report any individual suspected of having acute pulmonary or extra-pulmonary TB.

Infectious Disease Case Report Forms (mass.gov) 

Varicella

Please follow the link below to report a case or varicella or any known or suspected clusters of varicella.  Note: Shingles cases do not need to be reported.

Infectious Disease Case Report Forms (mass.gov) 

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