Forms

• School Health Forms 

• Addendum to the Application for Examination or Employment
• Employment Form(365KB, pdf) 

• Immunization Laws and Regulations
  
  • Medical Exemption Certificate (3-1-2023)    

• Letter of Support Request Form

• "Do Not Resuscitate" (DNR) Transfer Form
• "Do Not Resuscitate" (DNR) Bracelet Order Form

• Adverse Event Forms for Health Care Facilities 
  • Adverse Event Power Point Presentation 4/20/17
  • Adverse Event Web based User Manual 4/20/17
  • Adverse Event Reporting Form AE #1, AE #2 (Word)
  • Adverse Event Reporting Form (effective 1/1/17)
  • Adverse Event Reporting Directions
• Late Adopter Webinars
  • Late Adopters Part 1
  • Late Adopters Part 2
  • Group One Late Adopters Part 3
• NQF Glossary Appendix B
• Adverse Event Power Point Presentation
• CT Adverse Event Webinar Dec. 16, 2016 (video)
• Licensing & Certification Forms
• Practitioner Licensure Complaint Reporting
• Facility Licensing & Investigations Section Complaint Submission
• Strike Contingency Plan Documents
  • Exhibit A: Strike Contingency Plan
  • Exhibit B: Physical Plant Questionnaire
  • Exhibit C: Staffing Level Pattern
  • Exhibit D: Acuity Needs Form
  • Exhibit E: Staffing 
  • Exhibit F: Pressure Sores
  • Exhibit G: Licensure and Registry

• Reportable Event Forms for Long Term Care Facilities 
  • Word
  • PDF

• Clinical Laboratory & Blood Collection Facility Forms                  
  • CT-Blood Bank Application
  • CT-Blood Collection Facility Application
  • CT-Laboratory Personnel List
  • CT List of Tests Annual Volume
  • CT Change in Laboratory Director Form
  • Change in Ownership Form
  • EUA Attestation for CLIA Certificate of Waiver Laboratories

Office of Health Care Access

Reportable Disease Reporting Forms

Current lists of Provider and Laboratory Reportable Diseases

As reported in the January 2024 Connecticut Epidemiologist Newsletter

Reportable Disease Confidential Case Report, PD-23

• Instructions for completing the PD-23

Laboratory Report of Significant Findings, OL-15C

• Instructions for completing the 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.

• Casetivity Provider Portal User Guide

Adult HIV/AIDS Case Report

Borrelia miyamotoi Case Report Form

Facility Gastrointestinal Outbreak Report

Hospital instructions for Influenza Surveillance and Reporting

• Hospitalized and Fatal Cases of Influenza

MERS Person Under Investigation (PUI) Form

• Instructions for requesting MERS testing at the State Public Health Laboratory
  

Physician's Report of Occupational Disease

Sexually Transmitted Diseases, STD-23

Vaping Lung Injury Case Report Form

Varicella Case Report   

Tuberculosis Control Program Forms 

• Clinical Test Requisition
  • Laboratory Instructions for Influenza Testing and Surveillance
• 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 01/09/2024.