Forms

• School Health Forms 

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

• Medical Exemption Form (English – April , 2011)
• Medical Exemption Form (Spanish – June, 2011)
  • (Declaración de Certificación de Exoneración Médica)
• Medical Exemption Form (Polish – June, 2011)
  • (Zaswiadczenie o zwolnieniu z przyczyn medycznych)
• Medical Exemption Form (Brazilian Portuguese – June, 2011)
  • (Declaração da certificação de dispensa médica)
• Medical Exemption Form (Haitian Creole – June, 2011)
  • (Deklarasyon sou Sètifika Egzanpsyon Medikal)
• Medical Exemption Form (Traditional Chinese – June, 2011)
  • 
    
• Religious Exemption Form (English – July 1, 2015)

• 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 State application for Clinical Laboratory License
  • CT-Blood Bank Application
  • CT-Blood Collection Facility Application
  • CT-Laboratory Personnel List
  • CT List of Tests Annual Volume

Office of Health Care Access

Reportable Disease Reporting Forms

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.

• Guidance for Healthcare Professionals
• Guidelines for Collecting, Handling and Testing Specimens
• Laboratory Biosafety Guidelines

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

• Instructions for completing the PD-23

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

• Instructions for completing the OL-15C

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   

The following forms are available on the Tuberculosis Forms page:

• Tuberculosis Surveillance Report for Latent TB Disease and LTBI Reporting
• Tuberculosis Treatment and Follow-up Care Report Form
• Clinical Test Requisition, OL-9B
• Nucleic Acid Amplification (NAA)
• Contact Investigation Forms, TB-5
• Patient Management (Discharge) Plan 

• 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