Connecticut providers report chancroid, chlamydia, gonorrhea, neonatal herpes (under 60 days of age) and syphilis on STD-23, as required by CGS 19a-215. STDs are Category 2 diseases, so the report is due within 12 hours of recognition or strong suspicion. The form records patient details, diagnosis and syphilis stage, test date and lab confirmation, treatment and partner notification choices.
The attending physician, or the person reporting for a hospital or facility, completes the form, including the facility type.
Download the current version from the source each time; forms change without notice.
Sexually Transmitted Disease Confidential Case Report Form
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Chancroid, chlamydia, gonorrhea, neonatal herpes in infants under 60 days old, and syphilis, including congenital syphilis. HIV goes on Connecticut's separate HIV case report form, and congenital syphilis is also a Category 1 disease that must be phoned in.
Yes. The report goes to both the local Director of Health of the town where the patient lives and the DPH STD Control Program, by fax or by mail in a CONFIDENTIAL envelope. For patients who live out of state, send both copies to DPH.