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
Immunizations Exemption Forms


Immunizations Laws and Regulations           
Grant Letter of Support Request
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


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.


Reportable Disease Confidential Case Report, PD-23 (revised 2/13/2020 with inclusion of Coronavirus, COVID-19)

Laboratory Report of Significant Findings, OL-15C (revised 2/13/2020 with the inclusion of SARS-CoV-2)

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

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