Form PD-23 "Reportable Disease Confidential Case Report Form" - Connecticut

What Is Form PD-23?

This is a legal form that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 13, 2020;
  • The latest edition provided by the Connecticut State Department of Public Health;
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  • Fill out the form in our online filing application.

Download a fillable version of Form PD-23 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download Form PD-23 "Reportable Disease Confidential Case Report Form" - Connecticut

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Department of Public Health
State of Connecticut
410 Capitol Avenue, MS#11FDS
Reportable Disease Confidential Case Report Form PD-23
P.O. Box 340308
(rev. 02/13/2020)
Hartford, CT 06134-0308
For information or weekday disease reporting call 860-509-7994. For reporting on evenings, weekends, and holidays call 860-509-8000.
Instructions for Submitting the PD-23
The Commissioner of the Department of Public Health (DPH) is required to declare an annual list of Reportable Diseases, Emergency Illnesses and Health
Conditions, which has two parts: (A) reportable diseases; and (B) reportable emergency illnesses and conditions. This three-part form is to be used for
reporting of the reportable diseases in Part A, as required under Sections 19a-36-A3 and 19a-36-A4 (see back of form) of the Public Health Code and Sections
19a-2a and 19a-215 of the Connecticut General Statutes. Mail the white copy to the Connecticut Department of Public Health, Epidemiology and Emerging
Infections Program at the address above. Mail the canary copy to the Director of Health of the patient’s town of residence. Retain the pink copy in the patient’s
medical record. Mail reports in envelopes marked “Confidential.” Fillable PDF forms are found at: https://portal.ct.gov/DPH/Communications/Forms/Forms.
Use Other Forms or Methods to Report
Epidemiology and Emerging Infections Program
860-509-7994
Immunization Program
860-509-7929
Confidential Case Report Form PD-23
FAX
860-509-7910
Chickenpox (Varicella) Case Report Form
Hospitalized and Fatal Cases of Influenza Case Report Form
Occupational Diseases
860-509-7740
Physician’s Report Form
Healthcare-associated Infections
860-509-7995
Use the National Healthcare Safety Network (NHSN)
Sexually Transmitted Diseases
860-509-7920
HIV/AIDS
860-509-7900
STD-23 Form
FAX 860-509-7275
Adult HIV Confidential Case Report Form
FAX
860-509-8237
Tuberculosis
860-509-7722
Injury and Violence Surveillance Unit
860-509-8251
Tuberculosis Surveillance Report Form
FAX 860-509-7743
E-cigarette or vaping product use associated lung
injury (EVALI) Case Report Form
FAX
860-509-7910
Category 1 Diseases:
Report immediately by telephone (860-509-7994) on the day of recognition or strong suspicion of disease for those diseases
marked with a telephone (). On evenings, weekends, and holidays call 860-509-8000. These diseases must also be reported
by mail within 12 hours.
Category 2 Diseases:
All other diseases not marked with a telephone must be reported by mail within 12 hours of recognition or strong suspicion.
PART A: REPORTABLE DISEASES
Acquired Immunodeficiency Syndrome (1,2)
Hepatitis B
Poliomyelitis
Acute flaccid myelitis
Powassan virus infection
acute infection (2)
Q fever
Acute HIV infection
HBsAg positive pregnant women
Rabies
Anthrax
Hepatitis C
Ricin poisoning
Babesiosis
acute infection (2)
Borrelia miyamotoi disease
Rocky Mountain spotted fever
perinatal infection
Botulism
Rubella (including congenital)
positive rapid antibody test result
Brucellosis
Salmonellosis
HIV-1/HIV-2 infection in: (1)
California group arbovirus infection
SARS-CoV
persons with active tuberculosis disease
Campylobacteriosis
Shiga toxin-related disease (gastroenteritis)
persons with latent tuberculosis infection
Candida auris
Shigellosis
persons of any age
Silicosis
Chancroid
pregnant women
Chickenpox
Smallpox
HPV: biopsy proven CIN 2, CIN 3, or AIS or
Chickenpox-related death
St. Louis encephalitis virus infection
their equivalent (1)
Chikungunya
Staphylococcal enterotoxin B pulmonary
Influenza-associated death (6)
Chlamydia (C. trachomatis)(all sites)
poisoning
Influenza-associated hospitalization (6)
Cholera
Staphylococcus aureus disease, reduced
Legionellosis
Coronavirus, COVID-19
or resistant susceptibility to vancomycin (1)
Listeriosis
Cryptosporidiosis
Staphylococcus aureus methicillin-resistant
Lyme disease
disease, invasive, community acquired (3, 9)
Cyclosporiasis
Malaria
Dengue
Staphylococcus epidermidis disease, reduced
Measles
Diphtheria
or resistant susceptibility to vancomycin (1)
Melioidosis
E-cigarette or vaping product use associated
Syphilis
Meningococcal disease
lung injury (EVALI)
Tetanus
Mercury poisoning
Eastern equine encephalitis virus infection
Trichinosis
Mumps
Ehrlichia chaffeensis infection
Tuberculosis
Neonatal bacterial sepsis (7)
Tularemia
Escherichia coli O157:H7 gastroenteritis
Neonatal herpes (≤ 60 days of age)
Typhoid fever
Gonorrhea
Occupational asthma
Group A Streptococcal disease, invasive (3)
Vaccinia disease
Outbreaks:
Group B Streptococcal disease, invasive (3)
Venezuelan equine encephalitis virus infection
foodborne (involving ≥ 2 persons)
Haemophilus influenzae disease, invasive (3)
Vibrio infection (
)
parahaemolyticus, vulnificus, other
institutional
Hansen’s disease (Leprosy)
Viral hemorrhagic fever
unusual disease or illness (8)
Healthcare-associated infections (4)
West Nile virus infection
Pertussis
Hemolytic-uremic syndrome (5)
Yellow fever
Plague
Hepatitis A
Zika virus infection
Pneumococcal disease, invasive (3)
FOOTNOTES
1. Report only to State.
5.
On request from the DPH and if adequate serum is available, send serum from
2. As described in the CDC case definition.
patients with HUS to the DPH Laboratory for antibody testing.
3. Invasive disease: from sterile fluid (blood, CSF, pericardial, pleural, peritoneal,
6.
Reporting requirements are satisfied by submitting the Hospitalized and Fatal
joint or vitreous), bone, internal body site, or other normally sterile site including
Cases of Influenza-Case Report Form in a manner specified by the DPH.
Clinical sepsis and blood or CSF isolate obtained from an infant ≤ 72 hours of age.
muscle.
7.
Individual cases of “significant unusual illness” are also reportable.
4. Report HAIs according to current CMS pay-for-reporting or pay-for-performance
8.
requirements. Detailed instructions on the types of HAIs, facility types and
9.
Community-acquired: infection present on admission to hospital, and person has
locations, and methods of reporting are available on the DPH website:
no previous hospitalizations or regular contact with the health-care setting.
http://www.portal.ct.gov/DPH/Infectious-Diseases/HAI/Healthcare-Associated-
Infections-HAIs.
Department of Public Health
State of Connecticut
410 Capitol Avenue, MS#11FDS
Reportable Disease Confidential Case Report Form PD-23
P.O. Box 340308
(rev. 02/13/2020)
Hartford, CT 06134-0308
For information or weekday disease reporting call 860-509-7994. For reporting on evenings, weekends, and holidays call 860-509-8000.
Instructions for Submitting the PD-23
The Commissioner of the Department of Public Health (DPH) is required to declare an annual list of Reportable Diseases, Emergency Illnesses and Health
Conditions, which has two parts: (A) reportable diseases; and (B) reportable emergency illnesses and conditions. This three-part form is to be used for
reporting of the reportable diseases in Part A, as required under Sections 19a-36-A3 and 19a-36-A4 (see back of form) of the Public Health Code and Sections
19a-2a and 19a-215 of the Connecticut General Statutes. Mail the white copy to the Connecticut Department of Public Health, Epidemiology and Emerging
Infections Program at the address above. Mail the canary copy to the Director of Health of the patient’s town of residence. Retain the pink copy in the patient’s
medical record. Mail reports in envelopes marked “Confidential.” Fillable PDF forms are found at: https://portal.ct.gov/DPH/Communications/Forms/Forms.
Use Other Forms or Methods to Report
Epidemiology and Emerging Infections Program
860-509-7994
Immunization Program
860-509-7929
Confidential Case Report Form PD-23
FAX
860-509-7910
Chickenpox (Varicella) Case Report Form
Hospitalized and Fatal Cases of Influenza Case Report Form
Occupational Diseases
860-509-7740
Physician’s Report Form
Healthcare-associated Infections
860-509-7995
Use the National Healthcare Safety Network (NHSN)
Sexually Transmitted Diseases
860-509-7920
HIV/AIDS
860-509-7900
STD-23 Form
FAX 860-509-7275
Adult HIV Confidential Case Report Form
FAX
860-509-8237
Tuberculosis
860-509-7722
Injury and Violence Surveillance Unit
860-509-8251
Tuberculosis Surveillance Report Form
FAX 860-509-7743
E-cigarette or vaping product use associated lung
injury (EVALI) Case Report Form
FAX
860-509-7910
Category 1 Diseases:
Report immediately by telephone (860-509-7994) on the day of recognition or strong suspicion of disease for those diseases
marked with a telephone (). On evenings, weekends, and holidays call 860-509-8000. These diseases must also be reported
by mail within 12 hours.
Category 2 Diseases:
All other diseases not marked with a telephone must be reported by mail within 12 hours of recognition or strong suspicion.
PART A: REPORTABLE DISEASES
Acquired Immunodeficiency Syndrome (1,2)
Hepatitis B
Poliomyelitis
Acute flaccid myelitis
Powassan virus infection
acute infection (2)
Q fever
Acute HIV infection
HBsAg positive pregnant women
Rabies
Anthrax
Hepatitis C
Ricin poisoning
Babesiosis
acute infection (2)
Borrelia miyamotoi disease
Rocky Mountain spotted fever
perinatal infection
Botulism
Rubella (including congenital)
positive rapid antibody test result
Brucellosis
Salmonellosis
HIV-1/HIV-2 infection in: (1)
California group arbovirus infection
SARS-CoV
persons with active tuberculosis disease
Campylobacteriosis
Shiga toxin-related disease (gastroenteritis)
persons with latent tuberculosis infection
Candida auris
Shigellosis
persons of any age
Silicosis
Chancroid
pregnant women
Chickenpox
Smallpox
HPV: biopsy proven CIN 2, CIN 3, or AIS or
Chickenpox-related death
St. Louis encephalitis virus infection
their equivalent (1)
Chikungunya
Staphylococcal enterotoxin B pulmonary
Influenza-associated death (6)
Chlamydia (C. trachomatis)(all sites)
poisoning
Influenza-associated hospitalization (6)
Cholera
Staphylococcus aureus disease, reduced
Legionellosis
Coronavirus, COVID-19
or resistant susceptibility to vancomycin (1)
Listeriosis
Cryptosporidiosis
Staphylococcus aureus methicillin-resistant
Lyme disease
disease, invasive, community acquired (3, 9)
Cyclosporiasis
Malaria
Dengue
Staphylococcus epidermidis disease, reduced
Measles
Diphtheria
or resistant susceptibility to vancomycin (1)
Melioidosis
E-cigarette or vaping product use associated
Syphilis
Meningococcal disease
lung injury (EVALI)
Tetanus
Mercury poisoning
Eastern equine encephalitis virus infection
Trichinosis
Mumps
Ehrlichia chaffeensis infection
Tuberculosis
Neonatal bacterial sepsis (7)
Tularemia
Escherichia coli O157:H7 gastroenteritis
Neonatal herpes (≤ 60 days of age)
Typhoid fever
Gonorrhea
Occupational asthma
Group A Streptococcal disease, invasive (3)
Vaccinia disease
Outbreaks:
Group B Streptococcal disease, invasive (3)
Venezuelan equine encephalitis virus infection
foodborne (involving ≥ 2 persons)
Haemophilus influenzae disease, invasive (3)
Vibrio infection (
)
parahaemolyticus, vulnificus, other
institutional
Hansen’s disease (Leprosy)
Viral hemorrhagic fever
unusual disease or illness (8)
Healthcare-associated infections (4)
West Nile virus infection
Pertussis
Hemolytic-uremic syndrome (5)
Yellow fever
Plague
Hepatitis A
Zika virus infection
Pneumococcal disease, invasive (3)
FOOTNOTES
1. Report only to State.
5.
On request from the DPH and if adequate serum is available, send serum from
2. As described in the CDC case definition.
patients with HUS to the DPH Laboratory for antibody testing.
3. Invasive disease: from sterile fluid (blood, CSF, pericardial, pleural, peritoneal,
6.
Reporting requirements are satisfied by submitting the Hospitalized and Fatal
joint or vitreous), bone, internal body site, or other normally sterile site including
Cases of Influenza-Case Report Form in a manner specified by the DPH.
Clinical sepsis and blood or CSF isolate obtained from an infant ≤ 72 hours of age.
muscle.
7.
Individual cases of “significant unusual illness” are also reportable.
4. Report HAIs according to current CMS pay-for-reporting or pay-for-performance
8.
requirements. Detailed instructions on the types of HAIs, facility types and
9.
Community-acquired: infection present on admission to hospital, and person has
locations, and methods of reporting are available on the DPH website:
no previous hospitalizations or regular contact with the health-care setting.
http://www.portal.ct.gov/DPH/Infectious-Diseases/HAI/Healthcare-Associated-
Infections-HAIs.
Department of Public Health
State of Connecticut
410 Capitol Avenue, MS#11FDS
Reportable Disease Confidential Case Report Form PD-23
P.O. Box 340308
(rev. 02/13/2020)
Hartford, CT 06134-0308
 Check for additional PD-23 forms, or call 860-509-7994.
Date Completed:
For information or weekday disease reporting, call 860-509-7994.
For reporting on evenings, weekends, and holidays, call 860-509-8000.
PLEASE PRINT
Disease & Patient Information
Disease Name
Patient Name (Last, First, MI)
Age
Date of Birth
Parent or Guardian Name
_________________
_____________________________________
_____
____________
________________________________
 Cell
Address (Street, City, State, Zip Code)
Phone
 Home
 Work
___________________________________________________________________________________
__________________________________
Gender
Race
Hispanic/Latino
(check all that apply)
 Male
 White
 Black/African American
 Yes
 Female
 Asian
 American Indian/Alaska Native
 No
 Other specify: ________________  Native Hawaiian/Other Pacific Islander
 Unknown
 Unknown
 Unknown
 Other specify: ________________________
Primary Language Spoken
Is Patient Pregnant
Did Patient Die of Illness
Is Condition Work Related
 English
 Yes – Due date: ______________
 Yes
 Yes – Occupation:___________________
 Spanish
 No
 No
 No
 Other: ______________________  Unknown
 Unknown
 Unknown
Is patient a (please check)
Did patient have recent international travel
 Health care worker
 Student/Day care attendee
 Yes
 No
 Unknown
 Day care worker
 Food handler
 LTC Facility resident
Country visited: _______________________
Name and address of workplace, school, day care or other facility:
Dates visited from: _____________________
____________________________________________________________________________________
to: ______________________
Clinical & Laboratory Information
Confirmatory information, include laboratory data, immunization status, dates, and specific comments:
Onset Date
Diagnosis Date
__________
____________
If specimen obtained, collection date: ___________________
Provider/Reporter & Hospital Information
Healthcare Provider
Phone
Facility Name
Address
____________________________
______________
_____________________________
__________________________________________
Person Completing Report
Phone
Fax
Report Date
Address (if different from above)
___________________________
______________
______________
_____________
__________________________________________
Hospital Name
City
State
Date Admitted
Date Discharged
Patient ID#
_____________________________________
______________________
______
_____________
______________
__________________
Viral Hepatitis
Lyme disease surveillance case definition signs and symptoms
Perinatal:
 Yes
 No
HBV:
When testing for Lyme disease consider testing for other tick-borne diseases.
 Yes
 No
HCV:
Symptoms:  Yes
 No
Physician diagnosed EM rash ≥ 5cm
 Yes
 No
 Unknown
Onset Date: __________________
 Yes
 No
 Yes
 No
 Unknown
Jaundice:
Onset Date: __________________
Arthritis (objective joint swelling)
Bell’s palsy or other cranial neuritis
 Yes
 No
 Unknown
ALT Result: ___________
Test Date: __________________
 Yes
 No
 Unknown
Bilirubin Result: __________ Test Date: __________________
Radiculoneuropathy
IgM anti-HAV:  Pos
 Neg
 Yes
 No
 Unknown
Test Date: ______________
Lymphocytic meningitis
 Pos
 Neg
 Yes
 No
 Unknown
HBsAg:
Test Date: ______________
Encephalomyelitis
IgM anti-HBc:  Pos
 Neg
Test Date: ______________
If yes, is antibody to B. burgdorferi
 Rapid
 Serology
 Yes
 No
 Unknown
Anti-HCV:
Method:
higher in CSF than serum
 Pos
 Neg
 Yes
 No
 Unknown
nd
rd
Test Date: ______________
2
or 3
degree atrioventricular block
HCV confirmed by:  RNA  Value: ____ Test Date: _________
Was patient diagnosed with Lyme disease
 HCV negative antibody test within the last 12 months
 Yes
 No
 Unknown
in current year?
HBV Chronic/Carrier:  Yes  No
 Unknown
 IDU  Non-injection street drugs
Lyme disease laboratory results
Risk Factors:
 Hemodialysis
 Multiple sex partners
EIA/IFA
Culture
 Contact w/ infected person
 Positive
 Negative
 Unknown
 Positive  Negative
 Unknown
(
)
household
sexual
 Blood Transfusion  Incarcerated
Western Blot: IgM
Western Blot: IgG
(
)
present
past
 MSM
 Other: __________
 Positive
 Negative
 Unknown
 Positive  Negative
 Unknown
(men who have sex with men)
State of Connecticut
Health Insurance Portability and Accountability Act (HIPAA) Guidelines
Pursuant to Connecticut General Statutes (CGS) § 19a-2a and § 19a-215 and to the Regulations of Connecticut State
Agencies Section 19a-36-A3 and Section 19a-36-A4, the requested information is required to be provided to the
Department of Public Health (DPH)
Please note that CGS § 52-146o(b)(1) authorizes the release of these records to the Department without the patient’s
consent. Additionally, the federal Privacy Regulations of the Health Insurance Portability and Accountability Act of 1996
(HIPAA) also authorize you, as a provider, to release this information without an authorization, consent, release,
opportunity to object by the patient, as information (i) required by law to be disclosed [HIPAA Privacy regulation, 45 CFR §
164.512(a)] and (ii) as part of the Department’s public health activities (HIPAA Privacy regulation, 45 CFR §
165.512(b)(1)(i)]. The requested information is what is minimally necessary to achieve the purpose of the disclosure, and
you may rely upon this representation in releasing the requested information, pursuant to 45 CFR § 164.514(d)(3)(iii)(A) of
the HIPAA Privacy regulations.
PHC Section 19a-36-A4 - Content of report and reporting of reportable diseases and laboratory findings.
Each report should include: 1) name, address, and phone number of the person reporting and of the physician attending;
2) name, address, date of birth, age, sex, race/ethnicity, and occupation of person affected; and 3) the diagnosed or
suspected disease, and date of onset. Reports must be mailed in envelopes marked “CONFIDENTIAL” within 12 hours of
recognition or strong suspicion to the:
1. Local Director of Health of the town
AND
2.
Connecticut Department of Public Health
in which the patient resides
410 Capitol Avenue, MS#11FDS
(Canary copy)
P.O. Box 340308
Hartford, CT 06134-0308
(White copy)
(Retain Pink copy for patient’s medical record.)
PHC Section 19a-36-A3 - Persons required to report reportable diseases and laboratory findings.
1. Every health care provider who treats or examines any person who has or is suspected to have a reportable
disease shall report the case to the local director of health or other health authority within whose jurisdiction the
patient resides and to the DPH.
2. If the case or suspected case of reportable disease is in a health care facility, the person in charge of such facility
shall ensure that reports are made to the local director of health and DPH. The person in charge shall designate
appropriate infection control or record keeping personnel for this purpose.
3. If the case or suspected case of reportable disease is not in a health care facility, and if a health care provider is
not in attendance or is not known to have made a report within the appropriate time, such report of reportable
diseases shall be made to the local director of health or other health authority within whose jurisdiction the patient
lives and DPH by:
a. the administrator serving a public or private school or day care center attended by any person affected or
apparently affected with such disease;
b. the person in charge of any camp;
c. the master or any other person in charge of any vessel lying within the jurisdiction of the state;
d. the master or any other person in charge of any aircraft landing within the jurisdiction of the state;
e. the owner or person in charge of any establishment producing, handling, or processing dairy products, other
food, or non-alcoholic beverages for sale or distribution;
f.
morticians and funeral directors
(rev. 02/13/2020)
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