Notice: This report form is to be used to report: (1) a newly diagnosed case of Covid-19 and (2) a possible Covid-19 vaccination breakthrough event. Report can also collect information on persons tested onsite at your facility or office using a rapid test.
Provider Letter
Form Instructions

Patient Information– please fill in all information

Cities in CT
Please Enter the Residence city of Patient

States Dropdown


Please select the date of birth of patient

Housing and Occupation

Pre-Existing Medical Conditions


Hospitalization and Outcome

Drop Down List



Symptom and Outpatient Care

Please record symptom onset date and all symptoms noted


Vaccine Breakthrough

For Vaccine Breakthrough Cases Only – defined as any Connecticut resident who has SARS-CoV-2 RNA or antigen detection in a specimen collected ≥14 days after completing the primary series (i.e. final dose) of an FDA-authorized Covid-19 vaccine



SARS-CoV-2 (Covid-19) Testing





Additional Testing Details