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 Specific Forms
 

Note: The following items are available for download from the State Public Health Laboratory Forms 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