Thank you for taking the time to complete this form. It is important for us to gather this information to understand the current outbreak and to prevent further illness. Please complete this form for all positive COVID-19 cases, new hospitalizations, and/or deaths. For hospitalizations: only report those admitted as a result of COVID-19 illness, including individuals tested in other healthcare settings.

Additional information not on this form can be entered into the bottom section Notes

For more information or questions about reporting, please contact CaseCoordinationManagement@dhhs.nh.gov, 603-271-4496, or visit: https://www.covid19.nh.gov/resources/general-provider-covid-19-resources-and-information.

General Information

Illness Information
Signs and Symptoms    
Please check if patient experienced any of the following signs and symptoms.    
Laboratory Testing    
Outcome/Hospital Information    
Vaccination Information    

Risk Factors/Reason for Testing
(check all that apply within 14 days prior to diagnosis or specimen collection date if asymptomatic)    
Please indicate any additional risk information not listed here in the notes section at the bottom of this form.

Health Care Provider

Additional Notes Section

Department Internal Section Please Skip