Tecovirimat (TPOXX) Administration Healthcare Provider Reporting Form

Please complete for each patient that was administered Tecovirimat (TPOXX)

NOTE: Completing this form does not replace the need to report individual monkeypox cases to the MDPH Epidemiology Division via the 24/7 phone line 617-983-6800.

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Healthcare Facility and Provider Information
Healthcare Facility Name (e.g. hospital or clinic)
Healthcare Provider Name: First
Healthcare Provider Name: Last
Healthcare Provider Email
Healthcare Provider Phone (10-digit)

Patient Information
Patient First Name
Patient Last Name
Patient Date of Birth
Patient Race (choose all that apply)
Patient Ethnicity Hispanic/Latinx or Spanish?

Testing and Treatment
Has patient been tested for monkeypox?
Has patient been reported to MA Department of Public Health as a suspected or confirmed monkeypox individual? Reminder: Completing this form does not replace the need to report individual monkeypox cases to the MDPH Epidemiology Division via the 24/7 phone line at: 617-983-6800
Is patient currently an outpatient or inpatient?
Date of tecovirimat (TPOXX) initiation?
Tecovirimat (TPOXX) administration route?
Was tecovirimat given through the Study of Tecovirimat for Human Mpox Virus (STOMP) trial?

TPOXX must be administered consistent with the Food and Drug Administration's (FDA's) Investigational New Drug (IND) regulations as applicable to the expanded access IND protocol (IND 116,039/CDC IRB# 6402). Please confirm that you have submitted all required regulatory forms to the CDC, or will submit them within the CDC's required timeline.

Facility Categorical

Race (DPH vax categories)

Age in Years at treatment initiation

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