DPH: Asthma Reporting Forms

Asthma Reporting Forms

Connecticut General Statute (CGS§ 10-206) requires that schools annually report to the Connecticut Department of Public Health (DPH) the total number of students who have asthma in each school and in each school district. School nurses will be required to report to DPH on all students with a provider diagnosis of asthma indicated on the Health Assessment Record (HAR). In order to collect this data, the DPH Asthma Program has established a statewide system for school-based asthma surveillance based on the school HAR. DPH will use this information to help determine asthma trends and distributions among school-aged children in Connecticut.
Asthma Reporting Forms School Year: 2015-2016

Starting school year 2013-2014, asthma reporting forms will be scanned into a database. Please read the Reporting Form User Guide before downloading the new reporting form.


Reporting Form User Guide (pdf)           {please}             Asthma Reporting Notice  (pdf)
                                            Asthma Reporting Dos & Do Nots (pdf)
Asthma Reporting Form Selection:
Electronic Reporting Form* (pdf) - Preferred

*Electronic form completion requires use of the most current version of Adobe Acrobat Reader.


Content Last Modified on 3/10/2016 10:34:22 AM