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Asthma Reporting Forms

Connecticut General Statute (CGS§ 10-206) requires that schools annually report to the Connecticut Department of Public Health (DPH) the total number of students who have asthma in each school and in each school district. School nurses will be required to report to DPH on all students with a provider diagnosis of asthma indicated on the Health Assessment Record (HAR). In order to collect this data, the DPH Asthma Program has established a statewide system for school-based asthma surveillance based on the school HAR. DPH will use this information to help determine asthma trends and distributions among school-aged children in Connecticut.

Accepting Data for 2016 – 2017 Academic Year

Deadline for Data Submission: October 30, 2017

Asthma Reporting Forms School Year: 2016-2017

Asthma reporting forms will be scanned into a database.

Please read the Reporting Form User Guide before downloading the new reporting form.

Reporting Form User Guide (pdf)           please            Asthma Reporting Notice  (pdf)
                                            Asthma Reporting Dos & Do Nots (pdf)
Asthma Reporting Form Selection (2016-2017):
*Electronic form completion requires use of the most current version of Adobe Acrobat Reader.

(Reporting forms for 2017-2018 is not yet available)

Need to submit data for the next Academic Year, 2017 - 2018?

Asthma School Form for 2017 – 2018

Electronic Reporting Form (pdf)

Paper Reporting Form  (pdf)