DPH: Provider Reporting

Provider Reporting

{Reportable Disease Logo}  
 
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 specialty forms are also available. Other methods approved by the Connecticut Department of Public Health (DPH) may also be used. All requested information must be supplied by the provider. Information to be reported is outlined below.
 
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 complete and submitted within 12 hours. For Category 2 diseases, a report form must be completed and submitted to the DPH within 12 hours of recognition or strong suspicion of disease. Category 1 diseases are identified by a telephone symbol on the PD-23 form. 
 
Persons required to report diseases, emergency illnesses and health conditions must report using the Reportable Disease Confidential Case Report Form PD-23 or other format approved by the DPH. The PD-23 and other disease specific reporting forms can be found at www.ct.gov/dph/forms. To order paper copies or if you have questions concerning provider reporting, please contact the Epidemiology and Emerging Infections Program at 860-509-7994.
    
Each Report Must Include
  • Full name, address, date of birth, race, ethnicity, age, sex, and occupation of person affected
  • Diagnosis or suspected disease
  • 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 
Distribution of Completed Report Forms
  • Mailed reports must be in envelopes marked "Confidential"
  • One copy must be mailed or faxed to the DPH
  • One copy must be mailed to the Director of Health of the patient's town of residence
  • One copy must be kept for the patient's medical records 
DPH Contact Information
 
Completed PD-23 forms should be mailed or faxed to the DPH:
Connecticut Department of Public Health
410 Capitol Avenue, MS#11FDS
P.O. Box 340308
Hartford, CT 06134-0308
 
Fax Number: 860-509-7910
For immediate reporting, as for Category 1 diseases, providers can call the Epidemiology and Emerging Infections Program at 
 860-509-7994
or for after hours, weekends, and holidays please call
860-509-8000
  
 
In the instance where specialty forms or electronic reporting are available, the PD-23 should not be used. Specialty forms are available for the diseases listed below. Some forms are available as fillable PDF documents. When possible, please use the fillable form.
 
 
Please contact the program below with any questions concerning reporting of that disease, form completion or ordering disease specific forms.
 

Healthcare Associated Infections (NHSN) *

860-509-7995

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

 

* NHSN, the National Healthcare Safety Network, is an online disease surveillance system for healthcare facilities and public health Healthcare Associated Infections (HAI) programs developed and maintained by the Centers for Disease Control and Prevention. The DPH HAI Program uses NHSN for Connecticut mandated public health reporting of HAI.  

 




Content Last Modified on 2/8/2017 7:23:55 AM