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Connecticut Tuberculosis Surveillance Report Form

Connecticut uses this 2-page form from the DPH Tuberculosis Control Program for the initial report of all TB disease, confirmed or suspected, and latent TB infection. It covers patient information, TST and IGRA screening, chest imaging, bacteriology with rifampin resistance, diagnosis and reason for evaluation, HIV and hepatitis testing, risk factors, the initial treatment regimen, and hospital and provider details.

Who completes it

The diagnosing or treating provider completes the form, and the person completing it adds their name, phone and the report date.

Submitting and payment

How to submit it
Fax the form to the DPH TB Program's confidential fax line and to the local health department. Tuberculosis is a Category 1 disease in Connecticut, so it is also phoned to DPH on the day of diagnosis or suspicion.
Who pays
There is no fee to file, and the form has no billing section.

Good to know

  • Attach copies of all imaging reports, all bacteriology results, and any positive HIV or hepatitis results.
  • If the patient was hospitalized, a discharge plan is required; the form asks whether a discharge or treatment plan was completed and where copies went.
  • The treatment section lists isoniazid, rifampin, ethambutol, pyrazinamide, pyridoxine, rifapentine and rifabutin doses, and who performs directly observed therapy.
  • Later updates go on the TB Treatment and Follow-up Care Report Form rather than a second surveillance report.

Get the official form

Download the current version from the source each time; forms change without notice.

Tuberculosis Surveillance Report Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Does latent TB infection need to be reported in Connecticut?

Yes. The surveillance form is headed 'Complete for ALL TB Disease and Latent TB Infection' and offers latent TB infection as a diagnosis alongside TB disease. Send it to the DPH TB Program and the local health department.

What TB risk factors does the Connecticut form ask about?

It asks about long-term care or correctional residence, homelessness, injection or other drug use, excess alcohol, contact with an infectious case, incomplete LTBI treatment, diabetes with A1C, end stage renal disease, immunosuppression, TNF-alpha antagonist therapy, organ transplant and cancer.