Forms
- Medical Exemption Form (English – April , 2011)
- Medical Exemption Form (Spanish – June, 2011)
- Medical Exemption Form (Polish – June, 2011)
- Medical Exemption Form (Brazilian Portuguese – June, 2011)
- Medical Exemption Form (Haitian Creole – June, 2011)
- Medical Exemption Form (Traditional Chinese – June, 2011)
- Religious Exemption Form (English – July 1, 2015)
- 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)
- Licensing & Certification Forms
- 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 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)
Laboratory Report of Significant Findings, OL-15C (revised 2/13/2020 with the inclusion of SARS-CoV-2)
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
Foodborne Disease Interview and Surveillance Forms
General Enteric Diseases Interview Forms
- Cryptosporidium Interview
- Salmonella & Campylobacter Interview
- Shigella Interview
- Yersinia Interview
Tuberculosis (TB) Disease, Latent TB Infection (LTBI) or TB/HIV Co-infection Forms
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
State Public Health Laboratory (SPHL) Forms
- 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