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

   


















PROVIDER/REPORTER & FACILITY INFORMATION