Forms

 
The following forms are useful for the protection and improvement of the health and safety of the people of Connecticut. Information provided to the Department of Public Health by submitting completed report forms may help prevent disease, injury and disability, and assure the condition in which people can be healthy. 
 
Department of Education
Employment
Immunizations Exemption Forms

 

Immunizations Laws and Regulations           
Grant Letter of Support Request
Healthcare
Licensing, Certification and Adverse Events
  • Reportable Event Forms for Long Term Care Facilities 

Office of Health Care Access

Reportable Disease Reporting Forms
 
 
Some diseases listed may require completion of a Reportable Disease Specific Form below. If so, it is not necessary to complete a PD-23 form.

Reportable Disease Confidential Case Report, PD-23

Laboratory Report of Significant Findings, OL-15C

Adult HIV/AIDS Case Report

Borrelia miyamotoi Case Report Form

Hospital instructions for Influenza Surveillance and Reporting

MERS Person Under Investigation (PUI) Form

Physician's Report of Occupational Disease

Sexually Transmitted Diseases, STD-23

Vaping Lung Injury Case Report Form

Varicella Case Report   


Foodborne Disease Interview and Surveillance Forms

General Enteric Diseases Interview Forms

Tuberculosis (TB) Disease, Latent TB Infection (LTBI) or TB/HIV Co-infection Forms

The following forms are available on the Tuberculosis Forms page:

State Public Health Laboratory (SPHL) Forms
The following forms are available on the SPHL Scientific Support Services page:
  • Clinical Test Requisition
  • Nucleic Acid Amplification (NAA) - Mycobacterium tuberculosis complex
  • Zika Virus Clinical Test Requisition
  • Request for Rabies Examination
  • Environmental Microbiology Drinking Water Examination
  • Environmental Microbiology Fresh Surface Water Submission
  • Environmental Microbiology Fresh Bathing Water Submission
  • Environmental Microbiology Pool Water Submission
  • Environmental Microbiology Marine Surface Water Submission
  • Environmental Microbiology Marine Bathing Water Submission
  • Environmental Microbiology Shellfish Seawater Submission
  • Inorganic Chemistry Drinking Water
  • Inorganic Chemistry Routine Non-Potable Water
  • Inorganic Chemistry Stream Survey
  • Inorganic Chemistry Wastewater (NPDES)
  • Inorganic Chemistry Environmental Lead Examination
  • Organic Chemistry, Radiochemistry, and Asbestos in Water