COVID-19 Community Levels Map Update, September 30, 2022:The Centers for Disease Control and Prevention has listed New Haven, Fairfield, Litchfield, Middlesex, Hartford, Tolland, and Windham Counties in the Medium/Yellow category as part of its COVID-19 Community Levels Map. New London County is listed in the Low/Green categories. Visit the CDC COVID-19 Community Levels Map for updates.


Monkeypox: Please visit our monkeypox webpage for the latest updates.

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
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

All forms should be downloaded and completed on your personal computer. Completed forms can be printed and submitted to DPH if required.

 

Current lists of Provider and Laboratory Reportable Diseases

As reported in the July 2022 Connecticut Epidemiologist Newsletter

Reportable Disease Confidential Case Report, PD-23 

Laboratory Report of Significant Findings, OL-15C

Find a Local Health Department

 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.

Adult HIV/AIDS Case Report

Borrelia miyamotoi Case Report Form

Facility Gastrointestinal Outbreak Report

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

                                                                                                                   This page last updated 09/30/2022.