Provider Reporting

Reportable Disease Logo 
 
The Reportable Disease Confidential Case Report Form PD-23 is the primary form used to report diseases, emergency illnesses and health conditions found on the current list. Disease specific forms are also available. All forms can be found on the DPH "Forms" page. Other methods of reporting, approved by the Connecticut Department of Public Health (DPH), may also be used. All requested information must be supplied by the provider. The minimum amount of required information to be reported is outlined below.
 
In Connecticut, provider reportable diseases, emergency illnesses and health conditions are classified as Category 1 or Category 2 diseases.
Category 1 diseases must be immediately called into the DPH on the day of recognition or strong suspicion of disease and a report form completed and submitted within 12 hours. (Category 1 diseases are identified by a telephone symbol on the PD-23 form.)
Category 2 diseases must be reported by completing and submitting the appropriate form to the DPH and local health director of the patient's town of residence within 12 hours of recognition or strong suspicion of disease.  
 
Persons required to report can contact the Epidemiology and Emerging Infections Program at 860-509-7994 to order 3-ply paper copies of the PD-23 or with questions concerning  reporting.

 

Each Report Must Include
  • Full name, address, date of birth, race, ethnicity, age, sex, and occupation of the person affected
  • Diagnosis of suspected disease (disease name)
  • Date of onset of illness
  • Full name, address, and telephone number of the provider
  • Full name, address, and telephone number of the person reporting and date of report
Distribution of Completed Report Forms
  • Mailed reports must be in envelopes marked "Confidential"
  • One copy must be mailed or faxed to the DPH
  • One copy must be mailed to the Director of Health of the patient's town of residence
  • One copy must be kept for the patient's medical record
Disease Specific Forms
When disease specific forms or electronic reporting are available, the PD-23 should not be used. Disease specific forms are available on the DPH "Forms" page for the diseases listed below. Some are available as fillable PDFs. When possible, please use the fillable form. The PD-23 can be downloaded to your computer, completed, and printed to be submitted via mail or fax to the DPH at the contact information below, and to the Local Health Department of the patient's town of residence. Disease specific forms should be completed and submitted to the DPH as instructed by the Program.

Please call the program directly with any questions concerning the forms or reporting.

Healthcare Associated Infections
860-509-7995

The DPH HAI Program uses the National Healthcare Safety Network (NHSN) for Connecticut mandated health reporting of HAI. NHSN is an online disease surveillance system for healthcare facilities and public health HAI programs developed and maintained by the Centers for Disease Control and Prevention.

HIV/AIDS - Adult HIV/AIDS Case Report Form
860-509-7900

Influenza - Hospitalized and Fatal Cases of Influenza Case Report Form 860-509-7994

Occupational Diseases - Physician's Report Form
860-509-7740

Sexually Transmitted Diseases - STD-23
860-509-7920

Tuberculosis Report Forms and Laboratory Testing Forms
860-509-7722

Varicella Case Report Form
860-509-7929

DPH Contact Information

Completed PD-23 forms should be mailed or faxed to the DPH at:

Connecticut Department of Public Health
410 Capitol Avenue, MS#11FDS
P.O. Box 340308
Hartford, CT 06134-0308

Phone: 860-509-7994 for immediate reporting of Category 1 diseases

              860-509-8000 for after hours, weekends, and holidays

FAX:      860-509-7910