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
Grant Letter of Support Request
Healthcare
Licensing, Certification and Adverse Events
- Adverse Event Forms for Health Care Facilities
- Late Adopter Webinars
- NQF Glossary Appendix B
- Adverse Event Power Point Presentation
- CT Adverse Event Webinar Dec. 16, 2016 (video)
- Practitioner Licensure Complaint Reporting
- Facility Licensing & Investigations Section Complaint Submission
- Strike Contingency Plan Documents
- Clinical Laboratory & Blood Collection Facility Forms
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 Reportable Diseases and Laboratory Findings
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.
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
Foodborne Disease Interview and Surveillance Forms
- Cryptosporidium Interview
- Salmonella & Campylobacter Interview in English in Spanish
- Shigella Interview
- Yersinia Interview
- Cholera and Other Vibrio Illness Surveillance Form
- Hepatitis A Surveillance Form
- Typhoid & Paratyphoid Fever Surveillance Form
Tuberculosis Control Program Forms
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 01/29/2026