Provider Reporting
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 needs to be supplied by the provider. The minimum amount of required information to be reported is outlined below.
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
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. Use 860-509-7994 for reporting on weekdays during business hours and 860-509-8000 for after hours, weekends and holidays
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.
For the most current reportable disease forms, please use those available online. Persons required to report can also contact the Epidemiology and Emerging Infections Program at 860-509-7994 with questions concerning reporting.
Distribution of Completed Report Forms
- One copy must be faxed to the DPH at 860-920-3131
- One copy must be sent 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. Disease specific forms should be completed and submitted to the DPH as instructed by the Program. Some are available as fillable PDFs and should be used as much as possible or when indicated. Fillable forms can be downloaded, completed, printed and faxed to DPH at 860-920-3131. One copy of the completed PD-23 should be sent to the Local Health Department of the patient's town of residence and one should also be kept in the patient's medical record.
Please call the program directly with any questions concerning forms or reporting.
Please call the program directly with any questions concerning 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
This page last updated 7/5/2024.