Connecticut Department of Public Health , Epidemiology Program 2026

1. Click ‘Get Form’ to open the Hospitalized and Fatal Cases of Influenza – Case Report Form in our editor.
2. Begin by entering the Patient Information. Fill in the Date of Birth, Last Name, First Name, Street Address, City, State, and Zip Code. Select the Gender and indicate if the patient is pregnant if applicable.
3. Complete the Race and Ethnicity sections by selecting the appropriate options provided. Indicate if the patient is a Health Care Worker or resides in a Long Term Care Facility by checking 'Yes', 'No', or 'Unknown' as applicable.
4. Proceed to Additional Information. Enter the Medical record number and select the Test method used for microbiologic tests. Indicate hospitalization status and provide details such as Hospital name, Date of admission, and Date of discharge.
5. Fill out information regarding Antiviral use by checking all that apply. Finally, complete the section for Person completing form with your name and phone number before saving or submitting.

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