DPH Submissions System
Connecticut Department of Public Health COVID-19 Healthcare Provider Report Portal
Notice: This report form is to be used to report a newly diagnosed case of COVID-19 based on either a positive PCR/NAAT test or a positive Antigen test for SARS-CoV-2.
Form Instructions
Patient Information– please fill in all information
Patient's Last Name
*
Patient's First Name
*
Patient's Middle Name
Street Address of Patient
*
Apt, Bldg
Patient's Resident City/Town
*
Cities in CT
Please Enter the Residence city of Patient
Patient's County
Patient's Resident State
*
Patient's Zip code
*
Best Contact Number for Patient
Number is
Cell
Home
Work
Check here if patient does not have a phone number
Patient's DOB (MM/DD/YYYY)
*
Please select the date of birth of patient
Select Patient's Race
*
White
Black or African American
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
Other
Specify
Unknown
Hispanic/Latino
Yes
No
Unknown
Refused to Answer
*
Gender(sex at birth)
Female
Male
Other
Unknown
*
Pregnant?
Yes
No
Unknown
Attend or Work in a Daycare or Childcare Setting
Patient attended daycare facility?
Yes
No
Unknown
Daycare Name
Daycare Town
Specify
Daycare State
Healthcare Facility?
Name of Facility/Employer
Facility Town
Specify
Facility State
Provide Patient Care?
Yes
No
Unknown
Veterinary Facility?
Veterinary Facility?
Yes
No
Name of Facility/Employer
Facility Town
Specify
Facility State
First Responder?
First Responder?
Yes
No
Name of Facility/Employer
Facility Town
Specify
Facility State
Retail with direct contact with public (e.g., grocery store)?
Retail with direct contact with public (e.g., grocery store)?
Yes
No
Name of Facility/Employer
Facility Town
Specify
Facility State
Works in a daycare facility?
Yes
Name of Facility/Employer
Facility Town
Specify
Facility State
Other
Other
Yes
No
Specify
Name of Facility/Employer
Facility Town
Specify
Facility State
Unknown
Is patient unemployed?
Is patient employment/occupation unknown?
Symptoms
Please record symptom onset date and all symptoms noted
Were there any symptoms associated with this illness/event?
Yes
No
Unknown
Date of onset (MM/DD/YYYY)
Chills
Yes
No
Unknown
Fever
Yes
No
Unknown
Temperature
Unit
Fahrenheit
Celsius
Headache
Yes
No
Unknown
Muscle aches/pains (myalgia)
Yes
No
Unknown
Rigors/shivers
Yes
No
Unknown
Sore throat
Yes
No
Unknown
Changes in the ability to taste or smell
Yes
No
Unknown
Cough
Yes
No
Unknown
Difficulty of Breathing/Shortness of Breath
Yes
No
Unknown
Vomiting
Yes
No
Unknown
Diarrhea
Yes
No
Unknown
Fatigue
Yes
No
Unknown
Abdominal pain
Yes
No
Unknown
Rhinorrhea (Runny nose)
Yes
No
Unknown
Did the patient develop pneumonia?
Yes
No
Unknown
Abnormal chest CT/x-ray?
Did the patient have acute respiratory distress syndrome (ARDS)?
Yes
No
Unknown
PROVIDER/REPORTER & FACILITY INFORMATION
Health Care Provider Last Name
*
Health Care Provider First Name
*
Facility Name
Facility/Provider Street Address
Facility/Provider Town
Facility/Provider State
Facility/Provider Phone number
*
Facility/Provider Fax number
Facility Email/Provider
Last Name of Person completing report
First Name of Person completing report
Additional Comments (if any)
Date Submitted
for dispaly allignment purpose
Submit
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