DOH Forms
The forms are listed alphabetically by form number in PDF and Word template format. feedback
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Form # Form Name/Title PDF/Word Instructions
AAS-5 Facility Inspection Worksheet (Resident Rights, Physical Plant and Environment, Safety, Dietary Services) pdf 36k
doc 114k
 
AAS-11 Nurse Staffing Report pdf 11k
doc 54k
 
AAS-22 Adult Medical Day Care Inspection Information pdf 31k
doc 73k
 
AAS-23 Pediatric Medical Day Care Inspection Information pdf 25k
doc 62k
 
AAS-24 Affidavit of Compliance Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs pdf 19k
doc 72k
 
AAS-40 Affidavit of Compliance with N. J. Licensure Standards for Adult Day Health Care Facilities pdf 14k
doc 44k
 
AAS-45 Reportable Event Record/Report pdf 18k
doc 56k
 
AAS-55 Declaration of Compliance with Advisory Standards pdf 69k
doc 175k
 
AAS-59 Medical Day Inspection Information pdf 29k
doc 77k
 
AAS-60 Consumer Resident/Patient Complaint Report pdf 18k
doc 56k
 
AAS-61 Medical Day Care Assessment and Survey
Exit Conference Guide
pdf 12k
doc 47k
 
AAS-80 Assisted Living Assessment and Survey
Exit Conference Guide
pdf 13k
doc 48k
 
AAS-81 Assisted Living Entrance Guide pdf 8k
doc 23k
 
AAS-84 Affidavit of Compliance with N. J. Licensure Standards for Pediatric Medical Day Care Facilities pdf 14k
doc 38k
 
ACH NJ Acute Care Hospitals Cost Reports  
 
Instructions
pdf 74k
doc 144k  
APC-4 Veterinarian Co-Payment Fee Submission pdf 8k
doc 28k
 
APC-5 Application and Consent for Sterilization of Pets pdf 15k
doc 44k
 
APC-6 Animal Population Control Program
Veterinarian's Agreement (FY 2015)
pdf 13k
doc 38k
 
APC-7 Payment Voucher / Veterinarian Reimbursement pdf 28k
doc 3063k
 
APC-11 Animal Population Control Program Proxy Authorization pdf 11k
doc 33k
 
APC-12 Shelter/Pound Annual Report pdf 13k
doc 91k
Instructions
pdf 13k
doc 32k  
ASB-3 Asbestos Management Plan
Inspection Cover Sheet (Form A)
pdf 12k
doc 42k
Guide to Completing Asbestos Management Plan Forms
pdf 34k
doc 45k  
ASB-4 Asbestos Management Plan
Room/Functional Space Inspection (Form B)
pdf 12k
doc 50k
 
ASB-5 Asbestos Management Plan
Cover Sheet (Form C)
pdf 13k
doc 53k
 
ASB-6 Asbestos Management Plan, Room/Functional Space Inspection
Response Actions (Form D)
pdf 14k
doc 65k
 
ASB-7 Asbestos Management Plan
Room/Functional Space
Boiler Room Response Actions (Form E)
pdf 14k
doc 68k
 
ASB-8 Asbestos Management Plan
Homogeneous Material Identification (Form F)
pdf 11k
doc 61k
 
ASB-9 Asbestos Management Plan
Listing of Laboratories Utilized for Sample Analysis (Form G)
pdf 8k
doc 33k
 
ASB-10 Asbestos Management Plan
Summary of Laboratory Samples (Form H)
pdf 10k
doc 51k
 
ASB-11 Asbestos Management Plan
Continuation Sheet (Form I)
pdf 11k
doc 33k
 
ASB-12 Asbestos Management Plan
Description of Chain of Command (Form J)
pdf 9k
doc 33k
 
ASB-13 Asbestos Management Plan
Plan for Reinspection (Form K)
pdf 9k
doc 33k
 
ASB-14 Asbestos Management Plan
Plan for Operations and Maintenance Activities (Form L)
pdf 10k
doc 34k
 
ASB-15 Asbestos Management Plan
Plan to Inform (Form M)
pdf 9k
doc 33k
 
ASB-16 Asbestos Management Plan
Evaluation of Resources (Form N)
pdf 9k
doc 33k
 
ASB-17 Asbestos Management Plan
Previous/Current Asbestos Abatement Log
(Form O)
pdf 9k
doc 33k
 
ASB-18 Asbestos Management Plan
Major/Minor Fiber Release Episode Log (Form P)
pdf 10k
doc 34k
 
ASB-19 Asbestos Management Plan
Statement of Ensurances (Form Q)
pdf 18k
doc 40k
 
ASB-26 Facility Inspection Worksheet - Asbestos pdf 16k
doc 70k
 
ASB-41 Notification of Asbestos Abatement pdf 14k
doc 69k
 
BACT-44 Bacteriological Sample Submittal pdf 18k
doc 95k
 
BACT-109 Request for Identification of Enteric Pathogen, Parasite or Bacteriological Culture pdf 23k
doc 45k
 
CB-2 Fatal/Serious Accident Report pdf 23k
doc 99k
 
CB-11 Application for Certificate of Approval
to Operate a Youth Camp
pdf 16k
doc 61k
 
CB-14 Application for Certificate of Approval>
to Operate a Youth Camp
[Single Sport Youth Camp (SSYC)]
pdf 18k
doc 87k
 
CB-15 Annual Accident Report Youth Camp Safety Act pdf 13k
doc 65k
Instructions and Codes for Annual Accident Report
pdf 10k
doc 24k  
CB-17 Youth Camp Self-Inspection Report (for Youth Camp Operators) pdf 23k
doc 125k
 
CB-18 Youth Camp Safety Detailed Data Sheet (for Local Health Inspectors) pdf 69k
doc 224k
 
CB-19 Youth Camp Safety Detailed Data Sheet (for Youth Camp Operators) pdf 74k
doc 319k
 
CB-20 Certification for the Replacement of Main Drain Covers in Pool/Spa pdf 20k
doc 55k
 
CCR-27 Donation Mail In Record pdf 17k
doc 35k
 
CDC-2 Report of Rabies Postexposure Treatment pdf 16k
doc 58k
 
CDC 50.42A Adult HIV Confidential Case Report Form
(formerly DHAS-44)
pdf 285k
 
 
CDC 50.42B Pediatric HIV Confidential Case Report Form
(formerly DHAS-45)
pdf 287k
 
 
CDC-52.5 Typhoid And Paratyphoid Fever Surveillance Report  
 
 
CDC-52.56 Legionellosis Case Report  
 
 
CDC-52.79 Cholera And Other Vibrio Illness Surveillance Report  
 
 
CDC-54.48 Cyclosporiasis Surveillance Case Report  
 
 
CDC-54.7 Trichinosis Surveillance Case Report  
 
 
CDC-LCR Listeria Case Report  
 
 
CDS-1 For Reporting Reportable Communicable Diseases pdf 17k
doc 86k
 
CDS-2 Request for Human WestNile Virus Testing - Patient Intake Form pdf 27k
doc 94k
 
CDS-4 Dead-Ill Bird Report/Lab Submission Form pdf 23k
doc 35k
 
CDS-6 Amoebiasis Report pdf 25k
doc 50k
 
CDS-7 Babesiosis Report pdf 34k
doc 51k
 
CDS-8 Creutzfeldt-Jacob Disease Report pdf 24k
doc 49k
 
CDS-9 Guillain-Barre Syndrome Report pdf 13k
doc 49k
 
CDS-10 Kawasaki Syndrome Disease Report pdf 12k
doc 44k
 
CDS-11 Patient Symptoms Line Listing (Respiratory Tract Infection) pdf 11k
doc 32k
 
CDS-12 Patient Symptoms Line Listing (Gastrointestinal Infection) pdf 13k
doc 44k
 
CDS-13 Food-Specific Attack Rate Worksheet pdf 10k
doc 31k
 
CDS-14 Lyme Disease Case Investigation pdf 13k
doc 46k
 
CDS-15 Hemolytic Uremic Syndrome (Postdiarrheal) Report pdf 12k
doc 42k
 
CDS-16 Epidemiology Surveillance Record (Hospital-Based Laboratory) pdf 13k
doc 93k
 
CDS-17 Hepatitis C Report pdf 15k
doc 53k
 
CDS-17A Hepatitis C Investigation Letter (short) pdf 9k
doc 31k
 
CDS-18 Report of Known or Suspected Avian Chlamydiosis (Psittacosis) pdf 17k
doc 44k
 
CDS-19 Domestic Health Assessment pdf 41k
doc 97k
Guidelines
pdf 30k
doc 32k  
CDS-25 Avian Influenza Screening Information pdf 19k
doc 66k
 
CDS-26 Speakers' Bureau Request pdf 10k
doc 31k
 
CDS-28 Gastrointestinal/Foodborne Illness Case Report pdf 26k
doc 92k
 
CDS-29 Salmonella / STEC (including E. coli O157:H7) Questionnaire pdf 41k
doc 254k
 
CDS-30 Outbreak Report for Long Term Care and Other Institutions pdf 27k
doc 139k
Instructions
pdf 20k
doc 27k  
CDS-31 Out-of-State Animal Bite Report pdf 12k
doc 40k
 
CDS-32 Zoonotic Disease Incident Report pdf 26k
doc 96k
 
CDS-33 Student Symptoms Line Listing pdf 11k
doc 11kk
 
CDS-34 Scabies Case Line List: Residents pdf 11k
doc 80k
 
CDS-35 Scabies Case Line List: Staff pdf 11k
doc 74k
 
CDS-L2 Hepatitis B Reporting Letter pdf 31k
doc 767k
 
CEHS-1 Child Care Center - Indoor Environmental Health Assessment Form A: Submission Information pdf 29k
doc 69k
 
CEHS-2 Child Care Center - Indoor Environmental Health Assessment Form B: Historical and Current Uses of Building and Site pdf 15k
doc 51k
 
CEHS-3 Child Care Center - Indoor Environmental Health Assessment Form C: Descriptions and Conditions of Building Components pdf 11k
doc 34k
 
CEHS-4 Child Care Center - Indoor Environmental Health Assessment Form D: Description of Heating and Cooling Systems pdf 9k
doc 32k
 
CEHS-5 Child Care Center - Indoor Environmental Health Assessment Form E: Water and Sewer Information pdf 9k
doc 31k
 
CEHS-6 Child Care Center - Indoor Environmental Health Assessment Form F: Hazardous Substances and Vapor Intrusion pdf 23k
doc 60k
 
CEHS-7 Child Care Center - Indoor Environmental Health Assessment Form G: Summary of Testing and Evaluation Results pdf 13k
doc 79k
 
CEHS-8 Child Care Center - Indoor Environmental Health Assessment Form H: Assessment Summary, Conclusions, Recommendations and Corrective Actions pdf 12k
doc 43k
 
CEHS-9 Indoor Environmental Consultant License Application pdf 20k
doc 59k
 
CEHS-10 Employee Qualifications: Lead Inspectors/Risk Assessor and Evaluation Contractor Information pdf 16k
doc 83k
 
CEHS-11 Employee Qualifications: Asbestos Inspectors pdf 17k
doc 99k
 
CEHS-12 Employee Qualifications: General Indoor Environmental Health Assessor pdf 12k
doc 49k
 
CEHS-13 Consultant/Employee Certification pdf 12k
doc 31k
 
CEHS-14 Employee Qualifications: Radon Certification Information pdf 16k
doc 84k
 
CEHS-15 Child Care Center - DOH Subsequent Notification pdf 21k
doc 49k
 
CEHS-16 Indoor Environmental Consultant License Renewal Application pdf 78k
doc 62k
 
CEHS-17 Statement of Education and Experience Requirements
Lead Inspector / Risk Assessor
pdf 9k
doc 43k
 
CEHS-18 Statement of Education and Experience Requirements
Supervisor for Housing and Public Buildings
pdf 8k
doc 43k
 
CEHS-19 Statement of Education and Experience Requirements
Supervisor for Commercial Buildings and Superstructures
pdf 8k
doc 42k
 
CEOH-1 Checklist for Public Recreational Bathing Facilities pdf 20k
doc 101k
 
CEOH-2 Notification of Non-Friable Asbestos Work Activities pdf 13k
doc 57k
 
CEOH-3 Notification of Non-Friable Asbestos Work Activities Related to Superstorm Sandy pdf 13k
doc 60k
 
CEOH-4 Contractor Information for Non-Friable Asbestos Work Activities
Exemption Request
pdf 26k
doc 74k
 
CES-4 Request for Level A - Aggregate Data pdf 10k
doc 49k
 
CES-7 Cancer Registry Survey pdf 16k
doc 98k
 
CES-8 Cancer Data Software Information Request pdf 18k
doc 109k
 
CES-9 Hematology/Oncology Information Request pdf 17k
doc 105k
 
CES-12 Hematology/Oncology Physician Report pdf 13k
doc 59k
 
CES-14 Radiation Therapy Facility Report Form pdf 13k
doc 58k
 
CES-15 Ambulatory Surgery Center Report Form pdf 13k
doc 57k
 
CES-17 Dentist Report Form pdf 13k
doc 57k
 
CES-18 Laboratory Report Form pdf 13k
doc 57k
 
CES-19 Hospice Program Report Form (09701) pdf 13k
doc 43k
 
CES-40 Physician Report Form (Non-Hospital Source) pdf 13k
doc 57k
 
CH-2 Child Health Record pdf 20k
doc 142k
 
CH-2A Child Health Conference - Health Assessment (Infancy: 2-6 Weeks) pdf 19k
doc 72k
 
CH-2B Child Health Conference - Health Assessment (Infancy: 2 Months) pdf 19k
doc 70k
 
CH-2C Child Health Conference - Health Assessment (Infancy: 4 Months) pdf 19k
doc 66k
 
CH-2D Child Health Conference - Health Assessment (Infancy: 6 Months) pdf 19k
doc 72k
 
CH-2E Child Health Conference - Health Assessment (Infancy: 9 Months) pdf 19k
doc 71k
 
CH-2F Child Health Conference - Health Assessment (Infancy: 12 Months) pdf 19k
doc 70k
 
CH-2G Child Health Conference - Health Assessment (Childhood: 15 Months) pdf 19k
doc 69k
 
CH-2H Child Health Conference - Health Assessment (Childhood: 18 Months) pdf 18k
doc 69k
 
CH-2I Child Health Conference - Health Assessment (Childhood: 2 Years) pdf 29k
doc 72k
 
CH-2J Child Health Conference - Health Assessment (Childhood: 3 Years) pdf 19k
doc 71k
 
CH-2K Child Health Conference - Health Assessment (Childhood: 4 Years) pdf 19k
doc 71k
 
CH-2L Child Health Conference - Health Assessment (Childhood: 5 Years) pdf 19k
doc 71k
 
CH-2M Child Health Conference - Health Assessment (Childhood: 6 Years) pdf 19k
doc 69k
 
CH-2N Child Health Conference - Health Assessment (Childhood: 7 Years) pdf 18k
doc 69k
 
CH-2O Child Health Conference - Health Assessment (Childhood: 8 Years) pdf 18k
doc 69k
 
CH-2P Child Health Conference - Health Assessment (Childhood: 9 Years) pdf 19k
doc 65k
 
CH-2Q Child Health Conference - Health Assessment (Childhood: 10-12 Yrs) pdf 19k
doc 72k
 
CH-2R Child Health Conference - Health Assessment (Childhood: 13-15 Yrs) pdf 19k
doc 73k
 
CH-2S Child Health Conference - Health Assessment (Childhood: 16-20 Yrs) pdf 18k
doc 70k
 
CH-5 Child Health Conference Encounter Record pdf 35k
doc 35k
 
CH-7 Child Health Services Quarterly Summary Report pdf 35k
doc 70k
Instructions
pdf 28k
doc 33k  
CH-8 Patient Referral pdf 38k
doc 31k
 
CH-14 Universal Child Health Record (Printed copies of the CH-14 form are available by contacting the Child Health Program at 609-292-5666.) pdf 36k
doc 68k
Instructions
pdf 28k
doc 34k  
CH-15 Care Plan for Children with Special Health Needs pdf 29k
doc 88k
Instruction
pdf 24k
doc 30k  
CH-16 Hearing Screening Report pdf 60k
doc 82k
 
CHEM-44 Organic and Inorganic Chemistry Sample Submittal pdf 20k
doc 101k
 
CL-3 Application for a Clinical Laboratory License (Onsite Testing Only) pdf 79k
doc 463k
Laboratory Personnel Excel Spread Sheet  
CL-8 Blood Bank Annual Statistics (Out of Hospital and Emergency Only Transfusion Facilities) pdf 18k
doc 34k
 
CL-8A Blood Bank Annual Statistics (Hospitals) pdf 38k
doc 199k
 
CL-9 Disclosure of Ownership and Control Interest pdf 18k
doc 54k
 
CL-13 Blood Bank Annual Statistics (Hematopoietic Progenitor Cell Facilities) pdf 15k
doc 29k
 
CL-14 Blood Bank Annual Statistics (Perioperative Autologous Blood Collection and Administration Facilities) pdf 17k
doc 30k
 
CL-16 Application for a Blood Bank License pdf 33k
doc 240k
 
CL-17 Blood Bank Annual Statistics (Umbilical Cord Blood Facilities) pdf 15k
doc 29k
 
CL-18 Application for a Clinical Laboratory License (Collection Station Only) pdf 13k
doc 43k
 
CL-21 Error/Accident Report pdf 9k
doc 33k
 
CL-34 Laboratory Personnel Qualification Appraisal pdf 18k
doc 122k
 
CL-40 Blood Bank Personnel Qualification Appraisal pdf 65k
doc 79k
 
CL-44 Transfusion Reaction Report pdf 8k
doc 31k
 
CL-50 Brokers and Reagent Manufactureres - Annual Statistical Data pdf 50k
doc 59k
 
CL-51 Blood Centers - Annual Statistical Data pdf 29k
doc 129k
 
CL-58 Blood Bank License Fee pdf 8k
doc 26k
 
CMS-116 Clinical Laboratory Improvement Amendments (CLIA) Application for Certification  
 
 
CN-1 Application-Full Review Certificate of NeedLong Term Care Facilities: General Long Term Care Beds; Specialized Long Term Care Beds pdf 85k
doc 440k
 
CN-3 Application for Certificate of Need for Hospital-Related Projects pdf 76k
doc 503k
 
CN-4 Application for Certificate of Need for Designation as a Perinatal Facility pdf 54k
doc 218k
 
CN-7 Application for New or Amended Acute Care Facility License pdf 55k
doc 294k
Fees for Licensure and Inspection  
CN-10 Annual Report of Megavoltage Radiation Unit pdf 17k
doc 60k
 
CN-19 Certificate of Need Application - Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a) pdf 35k
doc 118k
 
CN-28 Application for Waiver pdf 20k
doc 37k
 
CT-11 Records Release Authorization pdf 23k
doc 134k
 
CT-11A Records Release Authorization (spanish) pdf 23k
doc 21k
 
CT-14 HIV Consent Form (Serology) pdf 22k
doc 21k
 
CT-24 HIV Confidential Consent Form (Serology) pdf 20k
doc 21k
 
CT-24A HIV Confidential Consent Form (Serology) (spanish) pdf 20k
doc 24k
 
CT-28 HIV Consent (Rapid Testing) - Confidential and Anonymous Testing pdf 10k
doc 24k
 
CT-28A HIV Consent (Rapid Testing) (Confidential and Anonymous) (spanish) pdf 12k
doc 24k
 
CT-28B HIV Consent (Rapid Testing) (Confidential and Anonymous) (Creole) pdf 10k
doc 23k
 
CT-29 HIV Consent (Rapid Testing) - Confidential Testing Only pdf 9k
doc 23k
 
CT-29A HIV Consent (Rapid Testing) (Confidential Only) (spanish) pdf 12k
doc 12k
 
CT-29B HIV Consent (Rapid Testing) (Confidential Only) (Creole) pdf 10k
doc 23k
 
DAPC-27 Risk Reduction Plan pdf 27k
doc 32k
 
DAPC-103 Risk Reduction Plan (Abbreviated) pdf 23k
doc 24k
 
DHAS-1 Grant Application Checklist pdf 65k
doc 65k
 
DHAS-2 Fringe Benefit Breakdown pdf 7k
doc 26k
 
DHAS-8 Application for Eligibility for the HIV Home Care Program pdf 25k
doc 113k
Instructions
pdf 18k
doc 29k  
DHAS-9 Client Intake Record pdf 53k
doc 68k
 
DHAS-10 Physician Certification and Plan of Care pdf 35k
doc 36k
 
DHAS-20 Monthly Activity Report pdf 79k
doc 90k
 
DHAS-27 Application for Participation in the
AIDS Drug Distribution Program (ADDP)
and/or the
Health Insurance Continuation Program (HICP)
pdf 52k
doc 164k
 
DHAS-34 Renewal Application for Participation in the Health Insurance Continuation Program pdf 25k
doc 73k
 
DHAS-35 Title II Reports  
 
excel 1.51mb  
DHAS-37 Certification by Physician (ADDP/HICP) pdf 13k
doc 41k
 
DHAS-38 Certification by Pharmacist pdf 17k
doc 31k
 
DHAS-39 Health Insurance Information
Health Insurance Continuation Program (HICP)
pdf 13k
doc 51k
 
DHAS-43 Confidential Laboratory Report pdf 16k
 
 
DHAS-44 Adult HIV/AIDS Confidential Case Report
(See CDC 50.42A)
 
 
 
DHAS-45 Pediatric HIV/AIDS Confidential Case Report
(See CDC 50.42B)
 
 
 
EHS-1 Application for Reciprocal Lead Permit pdf 45k
doc 91k
 
EHS-2 Renewal Application for Lead Training Agency Certification pdf 17k
doc 51k
 
EHS-4 Initial Application for Asbestos Training Agency Certification pdf 64k
doc 69k
 
EHS-5 Renewal Application for Asbestos Training Agency Certification pdf 59k
doc 51k
 
EHS-6 Application for Reciprocal Asbestos Accreditation pdf 15k
doc 61k
 
EHS-10 Facility Inspection Worksheet - Lead pdf 22k
doc 74k
 
EHS-11 Inspection of Bathing Beaches pdf 20k
doc 62k
 
EHS-12 Inspection of Hot Tubs/Spas pdf 24k
doc 66k
 
EHS-13 Inspection of Swimming Pools pdf 24k
doc 80k
 
EHS-14 Inspection of Swimming Pools, Hot Tubs and Spas pdf 29k
doc 119k
 
EHS-15 Application for Approval as a NJ Asbestos Course Instructor pdf 22k
doc 65k
 
EHS-16 Application for Approval as a NJ Lead Course Instructor/Training Manager pdf 66k
doc 69k
 
EHS-21 Lead Training Course Notification pdf 15k
doc 40k
 
EHS-22 Application for Lead Permit Worker-Housing and Public Buildings pdf 28k
doc 62k
 
EHS-23 Application for Lead Permit Supervisor, Housing and Public Buildings pdf 35k
doc 87k
 
EHS-24 Application for Lead Permit Inspector/Risk Assessor pdf 37k
doc 95k
 
EHS-25 Application for Lead Permit Planner/Project Designer pdf 36k
doc 63k
 
EHS-26 Application for Lead Permit Worker, Commercial Buildings and Superstructures pdf 36k
doc 62k
 
EHS-27 Application for Lead Permit Supervisor, Commercial Buildings and Superstructures pdf 36k
doc 89k
 
EHS-28 Initial Application for Lead Training Agency Certification pdf 64k
doc 77k
 
EHS-29 Application for Replacement of Lead Permit pdf 35k
doc 56k
 
EHS-34 Application for Approval to Operate a Body Art Establishment (Permanent) For use by Local Health Department Officials only. pdf 17k
doc 72k
 
EHS-35 Application for Approval to Operate a Body Art Establishment (Temporary) For use by Local Health Department Officials only. pdf 16k
doc 60k
 
EHS-36 Body Art Infection/Injury Report For use by Local Health Department Officials only. pdf 33k
doc 91k
 
EHS-37 Asbestos Training Course Notification pdf 13k
doc 39k
 
EHS-38 Lead Training Course Proposal Checklist pdf 20k
doc 91k
 
EHS-39 Asbestos Training Course Proposal Checklist pdf 23k
doc 76k
 
EMS-3 EMT-Basic Instructor Endorsement - Initial pdf 14k
doc 38k
 
EMS-4 EMT-Basic Instructor Endorsement - Renewal pdf 15k
doc 44k
 
EMS-8 Vehicle Accident Report pdf 15k
doc 49k
 
EMS-10 EMT Verification Report pdf 12k
doc 40k
 
EMS-12 Incident Report pdf 13k
doc 39k
 
EMS-16 Survey Report for Mobility Assistance Vehicles (Sample) pdf 18k
doc 57k
 
EMS-19 Survey Report for Ambulance (Basic Life Support) (Sample) pdf 43k
doc 146k
 
EMS-20 Survey Report for Ambulance (Advanced Life Support) (Non-Transport) (Sample) pdf 50k
doc 153k
 
EMS-21 Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample) pdf 61k
doc 184k
 
EMS-24 Quarterly Report of Mobile Intensive Care Program pdf 56k
doc 249k
Instructions
pdf 61k
doc 93k  
EMS-25 Quarterly Report of Specialty Care Transport Units pdf 33k
doc 81k
Instructions
pdf 22k
doc 44k  
EMS-26 Quarterly Report for Basic Life Support Ambulances Providing Emergency Response pdf 30k
doc 92k
 
EMS-27 Quarterly Report for Air Medical Units pdf 39k
doc 116k
 
EMS-28 NJ/PA EMT Continuing Education Documentation pdf 21k
doc 60k
 
EMS-38 Staff Roster pdf 23k
doc 144k
 
EMS-40 Emergency Medical Technician - Application for Reciprocity pdf 15k
doc 62k
 
EMS-43 EMT-Basic Course Application and Schedule pdf 21k
doc 133k
 
EMS-44 Application for Accreditation - Emergency Medical Technician Education Program pdf 68k
doc 99k
 
EMS-49 EMT Training Fund / Continuing Education Course Final Reimbursement Report pdf 9k
doc 29k
 
EMS-50 Emergency Medical Technician Training Programs Certificate of Eligibility for the N. J. State Certification Examination pdf 10k
doc 31k
 
EMS-51 Continuing Education Voucher pdf 27k
doc 2797k
 
EMS-52 Basic Course Voucher pdf 27k
doc 2797k
 
EMS-53 Initial EMT Education Reimbursement Report pdf 8k
doc 29k
 
EMS-54 Emergency Medical Technician-Paramedic Provider Reciprocity Application pdf 14k
doc 38k
 
EMS-55 Emergency Medical Technician-Paramedic Provider Reciprocity Application Verification of EMT-Paramedic Training and Certification pdf 14k
doc 40k
 
EMS-56 Application for Certification as an Emergency Medical Technician-Basic Instructor pdf 13k
doc 45k
 
EMS-57 Basic Life Support (BLS) Application for Provider Recertification pdf 20k
doc 80k
 
EMS-60 Advanced Life Support Application for Provider Recertification pdf 18k
doc 55k
 
EMS-63 Form A / EMS First Responder
NJ Protocol for Scene Investigations of Infant and Child Deaths
pdf 23k
doc 109k
 
EMS-80 Certificate of Eligibility for EMT Education pdf 18k
doc 31k
Instructions  
EMS-81 Certificate of Eligibility for Continuing Education Courses pdf 8k
doc 29k
Instructions  
EP-5 New Jersey Medical Reserve Corps User Enrollment Request pdf 14k
doc 29k
 
F-2 Registration of Drug or Medical Device Manufacturing or Wholesale Drug or Medical Device Business pdf 68k
doc 402k
 
F-5 Initial Application for Certification to Sell Bottled Water or Bulk Water pdf 18k
doc 79k
 
F-8 Initial Application for License to Operate a Refrigerated Warehouse and/or Locker Plant pdf 14k
doc 33k
 
F-9 Initial Application for License to Operate a Non-Alcoholic Beverage Manufacturing Plant pdf 12k
doc 33k
 
F-12 Application for Certificate of Free Sale (CFS) pdf 18k
doc 41k
 
F-13 Renewal or Discontinuation of Application to Operate a Wholesale Drug or Medical Device Business pdf 23k
doc 71k
 
F-17 Application for Permit to Handle Nitrous Oxide pdf 13k
doc 34k
 
F-19 Renewal Application to Operate a Refrigerated Warehouse-Locker Plant pdf 15k
doc 41k
 
F-26 Self-Inspection Checklist (Wholesale) pdf 23k
doc 86k
 
F-27 Self-Inspection Checklist (Retail) pdf 21k
doc 74k
 
F-29 Initial Application for License to Operate a Wholesale Food-Cosmetic Establishment pdf 30k
doc 66k
 
F-30 Satisfactory Placard pdf 26k
doc 246k
Note  
F-31 Unsatisfactory Placard pdf 26k
doc 245k
Note  
F-32 Conditionally Satisfactory Placard pdf 26k
doc 26k
Note  
F-33 Sanitary Inspection Report pdf 22k
doc 253k
Note  
F-35 Retail Food Inspection Report (Local Health Departments) pdf 33k
doc 112k
Note  
F-37 Risk-Based Inspection Report (Local Health Departments) pdf 27k
doc 115k
Note  
F-39 Renewal Application to Operate a Non-Alcoholic Beverage and/or Bottling Plant pdf 15k
doc 41k
 
F-41 Renewal Application to Operate a Wholesale Food/Cosmetic Establishment pdf 15k
doc 43k
 
F-42 Renewal Application for Certification to Sell Bottled Water or Bulk Water pdf 21k
doc 87k
 
F-48 Application for Certification to Handle Oysters, Clams or Mussels pdf 13k
doc 38k
 
FHS-16 Initial Uniform Application for Services to Individuals 21 and Under with Developmental Disabilities pdf 33k
doc 61k
 
FHS-18 Formal Dispute Resolution Request pdf 16k
doc 38k
Formal Dispute Resolution Request Guidance (formerly titled "Program Guidelines")
pdf 28k
doc 155k  
FHS-18A Formal Dispute Resolution Request (Spanish)
(Solicitud de Resolution de Reclamo Formal)
pdf 15k
doc 41k
(Guia de Solicitud de Resolucion de Reclamo Formal)
pdf 28k
doc 156k  
FHS-19 Withdrawal of Dispute Resolution Request (formerly titled "Withdrawal of Complaint") pdf 9k
doc 27k
 
FHS-19A Withdrawal of Complaint (Spanish) pdf 8k
doc 28k
 
FHS-22 Request for Technical Assistance pdf 8k
doc 29k
 
F-L3 Certificate of Free Sale Package (English) (including F-L3 and F-12 Forms) pdf 32k
doc 766k
Guidelines for Requesting Certificates of Free Sale  
F-L4 Certificate of Free Sale Package (Spanish) (including F-L4 and F-12 Forms) pdf 32k
doc 767k
Guidelines for Requesting Certificates of Free Sale  
FS-5 Report of Expenditures and Request for Reimbursement for Construction Grants pdf 11k
doc 11k
 
FS-20A Report of Grant Expenditures pdf 15k
doc 80k
Instructions
pdf 15k
doc 25k

Budget/Cost Categories and Elements of Cost
pdf 10k
doc 23k  
FS-27 Notification of Licensed Public Accountant pdf 14k
doc 53k
Instructions
pdf 20k
doc 25k  
FS-40A Personnel Costs and Justification pdf 17k
doc 75k
 
FS-40B Consultant Services Costs and Justification pdf 12k
doc 44k
 
FS-40C Other Cost Categories and Justification pdf 12k
doc 41k
 
FS-45 Grant Progress Report pdf 11k
doc 30k
 
FS-57 Budget Revision Request pdf 14k
doc 23k
Budget/Cost Categories and Elements of Cost
pdf 11k
doc 23k

Instructions
pdf 9k
doc 23k  
FS-63 Statement of Program Income pdf 12k
doc 33k
 
FS-77 Application for Mini-Grant Funds pdf 18k
doc 60k
 
FS-91 Statement of Interest Earned from Advance Payments Deposited into an Interest Bearing Account pdf 11k
doc 31k
 
FS-D4 Instructions for Completion of "Application for Mini-Grant Funds" (FS-77) pdf 16k
doc 31k
 
GRANTS Grant Application Package - General pdf 90k
doc 321k
 
GRANTS Grant Application Package - Construction Grant (FS-26) pdf 10k
doc 35k
 
GRANTS Grant Application Package - Letter of Agreement pdf 14k
doc 82k
 
GRANTS Grant Application Package - Multi-Year 2nd and 3rd Year (FS-20) pdf 19k
doc 88k
 
HCQ-1 Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility (for use on or after January 1, 2007) (formerly HCQO-19) pdf 25k
doc 91k
 
HCQ-2 Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility - Root Cause Analysis (RCA) (for use on or after January 1, 2007) (formerly HCQO-20) pdf 19k
doc 62k
 
HCQ-3 Daily Patient Care Staffing: Inpatient Units pdf 17k
doc 54k
Instructions
pdf 13k
doc 24k  
HCQ-3A Daily Patient Care Staffing - Inpatient (Spanish) pdf 19k
doc 58k
Instructions
pdf 14k
doc 26k  
HCQ-4 Daily Patient Care Staffing: Emergency Department pdf 10k
doc 30k
Instructions
pdf 10k
doc 22k  
HCQ-4A Daily Patient Care Staffing - Emergency Department (Spanish) pdf 13k
doc 32k
Instructions
pdf 13k
doc 25k  
HCQ-5 Daily Patient Care Staffing: Post-Anesthesia Care Unit pdf 10k
doc 30k
Instructions
pdf 10k
doc 22k  
HCQ-5A Daily Patient Care Staffing - Post Anesthesia Care Unit (PACU) (Spanish) pdf 13k
doc 32k
Instructions
pdf 13k
doc 25k  
HCQ-6 Daily Patient Care Staffing-Other Licensed Health Care Professionals: Hospital-Wide pdf 10k
doc 28k
Instructions
pdf 10k
doc 22k  
HCQ-6A Daily Patient Care Staffing - Other Licensed Health Care Professionals, Hospital Wide (Spanish) pdf 11k
doc 29k
Instructions
pdf 11k
doc 25k  
HCQ-7 Cardiac Cathereterization Data Registry pdf 88k
doc 251k
Instructions
pdf 1036k  
HCQ-8 NJ Acute Stroke Registry pdf 48k
doc 207k
Instructions
pdf 409k  
HCQ-9 Open Heart Surgery Risk Stratification Project - Data Collection Form, Version 4.1
(formerly HCQO-22)
pdf 31k
doc 79k
Instructions
pdf 710k  
HCQO-16 Non-Confidential Release pdf 21k
doc 27k
 
HCQO-27 Quarterly Cardiac Data Submission Report pdf 12k
doc 37k
 
HFEL-3 Project Application for an Adult Day Health Services Facility pdf 18k
doc 43k
 
HFEL-4 Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility pdf 16k
doc 39k
 
HFEL-5 Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment pdf 10k
doc 34k
Instructions
pdf 8k
doc 22k  
HFEL-6 Resident Care Staffing Report pdf 10k
doc 29k
Instructions
pdf 12k
doc 23k  
HFEL-7 New Jersey Universal Transfer Form pdf 21k
doc 108k
Instructions
pdf 38k
doc 66k  
HFEL-8 Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership pdf 35k
doc 125k
Instructions
pdf 20k
doc 31k  
HIP-5 Laboratory PreScreening Worksheet pdf 15k
doc 54k
 
IEM-3 Specimens for Newborn Biochemical Screening pdf 86k
doc 71k
 
IMM Minimum Immunization Requirements for School Attendance in NJ pdf 29k
doc 34k
 
IMM-3 Annual College Immunization Status Report pdf 18k
doc 56k
 
IMM-5 Varicella Case Report pdf 24k
doc 104k
 
IMM-6 Vaccines for Children Program
Vaccine Usage Report
pdf 11k
doc 30k
 
IMM-7 Annual Immunization Status Report  
 
 
IMM-8 Standard School/Child Care Center Immunization Record
(To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.)
 
 
 
IMM-9 Personal Immunization Record
(To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.)
 
 
 
IMM-10 Rubella Surveillance Worksheet pdf 39k
doc 118k
 
IMM-11 Measles Surveillance Worksheet pdf 36k
doc 108k
 
IMM-12 Retrospective Immunization Audit / Survey pdf 14k
doc 111k
 
IMM-13 Flu Vaccine Tracking Record pdf 9k
doc 47k
 
IMM-14 Immunization Audit Report Worksheet pdf 17k
doc 193k
 
IMM-15 Immunization Audit Report pdf 24k
doc 51k
 
IMM-16 Provisional Admittance Student Tracking Record pdf 12k
doc 41k
 
IMM-18 Vaccines for Children Program
New Provider Profile: Adults
pdf 15k
doc 55k
 
IMM-19A-FORM Consent to Participate-NJIIS - Schools (Side 2, Form) (Spanish) pdf 10k
doc 28k
 
IMM-19A-MEMO Consent to Participate-NJIIS - Schools (Side 1, Memo) (Spanish) pdf 10k
doc 25k
 
IMM-19-FORM Consent to Participate-NJIIS - Schools (Side 2, Form) (English) pdf 10k
doc 25k
 
IMM-19-MEMO Consent to Participate-NJIIS - Schools (Side 1, Memo) (English) pdf 9k
doc 22k
 
IMM-20 Confidential Perinatal Hepatitis-B Case and Contact Report pdf 21k
doc 122k
Instructions for Completing the imm-20 Form
pdf 13k
doc 24k  
IMM-21 Mumps Surveillance Worksheet pdf 35k
doc 146k
 
IMM-22 Tetanus Surveillance Worksheet pdf 28k
doc 95k
Instructions
pdf 23k
doc 26k  
IMM-24 Pertussis Investigation Record pdf 30k
doc 178k
 
IMM-25 Vaccines for Children Program
New Provider Enrollment
pdf 14k
doc 34k
 
IMM-26 Vaccines for Children Program
New Provider Profile: Pediatrics
pdf 15k
doc 65k
 
IMM-28 Vaccines for Children Program
Eligibility/Vaccine Encounter Record
(pending revisions)
 
 
 
IMM-29 New Jersey Immunization Information System (NJIIS)
Request for Change of User Security Authorization/
Request for Password Reset
pdf 21k
doc 34k
 
IMM-30 Vaccines for Children Program
Provider Disenrollment Request
pdf 13k
doc 51k
 
IMM-31 Insured for Sure User Enrollment pdf 10k
doc 31k
 
IMM-32 NJIIS Consent to Participate (English) pdf 12k
doc 30k
 
IMM-34 Site Enrollment Request:
Early Hearing Detection and Intervention Program
pdf 12k
doc 31k
 
IMM-35 User Enrollment and Training Request:
Early Hearing Detection and Intervention Program
pdf 10k
doc 30k
 
IMM-40 New Jersey Immunization Information System (NJIIS)
Duplicate Record
pdf 20k
doc 50k
 
IMM-41 NJIIS User Enrollment and Training Request pdf 24k
doc 35k
 
IMM-42 Enrollment Request for New NJIIS Site pdf 18k
doc 39k
Instructions
pdf 13k
doc 25k  
IMM-43 User Confidentiality Statement for Access to NJIIS/ User Confidentiality Agreement pdf 14k
doc 32k
 
IMM-44 New Jersey Immunization Information System (NJIIS)
Declination of Newborn Automatic Enrollment
pdf 8k
doc 29k
 
IMM-45 Request for Change to NJIIS Immunization Record pdf 14k
doc 38k
 
IMM-46 Request for Copy of NJIIS Immunization Record pdf 13k
doc 33k
 
IMM-47 Registrant Withdrawal from NJIIS pdf 13k
doc 29k
 
IMM-PKG-A Vaccines for Children Program
Provider Enrollment Package (Adult)
pdf 25k
doc 95k
 
IMM-PKG-P Vaccines for Children Program
Provider Enrollment Package (Pediatric)
pdf 26k
doc 102k
 
IRB-1 Application for Initial Review pdf 53k
doc 178k
 
IRB-2 Application to Continue Human Subjects Research pdf 34k
doc 186k
 
IRB-3 Application to Modify Human Subjects Research pdf 17k
doc 50k
Instructions
pdf 31k
doc 78k  
LAB-3 Request for Microbiological Testing of Food Sample pdf 16k
doc 36k
 
LAB-5 Request for Testing of Suspected Select Agents and Chain of Custody pdf 25k
doc 66k
 
LAB-7 HIV Test Requistion pdf 8k
doc 8kk
 
LAB-10 Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT)
pdf 14k
doc 49k
 
LAB-46 Chain of Custudy Shipping Log pdf 10k
doc 36k
 
LCS-4 Communicable Disease Alert pdf 10k
doc 29k
 
LCS-5 Application for the Addition of Long Term Care Beds pdf 22k
doc 41k
 
LCS-8 Facility Reporting Incident Data and Analysis Yield (FRIDAY) pdf 51k
doc 125k
 
LCS-9 Application for a Long Term Care Facility License pdf 37k
doc 151k
 
LH-7 Application for Registered Environmental Health Specialist Examination pdf 60k
doc 206k
 
LH-8 Application for Health Officer Examination pdf 52k
doc 179k
 
LH-9 Uniform Shared Services Agreement (Template) for Local Public Health Services pdf 18k
doc 59k
Guidelines for Uniform Shared Public Health Services Agreement
pdf 20k
doc 26k  
LP-3 Report of Childhood Blood Lead Analysis by Independent Laboratory (for children 16 years of age and under) pdf 13k
doc 32k
 
LP-4 Hazard Assessment Questionnaire pdf 51k
doc 199k
 
LP-5 Environmental Intervention Report pdf 28k
doc 145k
 
LP-6 User Confidentiality Statement pdf 11k
doc 33k
 
LP-7 Notice of Violation Template pdf 24k
doc 34k
 
LP-8 Childhood Lead Poisoning Home Visit pdf 41k
doc 215k
 
LP-9 Nutritional Assessment pdf 17k
doc 51k
 
LP-10 Quality Assurance and Improvement pdf 19k
doc 42k
 
LP-11 Case Closure pdf 21k
doc 39k
 
LP-D1 Standard Housing Component Terminology (LP-D1) pdf 603k
doc 891k
 
LP-D2 Protocol for Data Entry pdf 22k
doc 33k
 
LTC-2 Notification form Long-Term Care Facility of Admission or Termination of a Medicaid Beneficiary  
 
 
LTC-4 Hospital Preadmission Screening Referral  
 
 
LTC-19 Request for Billing Assistance  
 
 
M-3 Initial Application for a Milk Plant or a Bulk Milk Hauler Permit pdf 22k
doc 64k
 
M-5 Initial Application for License to Manufacture Frozen Desserts pdf 15k
doc 38k
 
M-6 Renewal Application to Operate a Frozen Dessert Plant pdf 16k
doc 16kk
 
M-8 Renewal Application to Operate a Bulk Tank Unit/Milk Plant pdf 15k
doc 43k
 
MCCH-1 J-1 Visa Waiver Physician-Primary Care Survey, Initial/Biannual Service Report pdf 15k
doc 68k
 
MCCH-5 J-1 Visa Waiver Application for New Jersey pdf 26k
doc 112k
 
MCCH-5A Attachment A: Current Medical Staffing at Practice Site pdf 11k
doc 42k
 
MCCH-5B Attachment B: Health Care Resources Inventory pdf 10k
doc 50k
 
MCCH-5C Attachment C: Facility Current Sliding Fee Scale pdf 7k
doc 19k
 
MCCH-5D Attachment D: J-1 Physician Visa Waiver Statements pdf 8k
doc 25k
 
MCCH-6 Section 4-1, Health Facility's J-1 Visa Waiver Agreement pdf 15k
doc 31k
 
MCCH-7 Section 4-2, Physician J-1 Visa Waiver Affidavit and Agreement pdf 16k
doc 32k
 
MCCH-8 Section 5, J-1 Visa Waiver Required Application Enclosures pdf 9k
doc 20k
 
MMP-1 Law Enforcement Incident Report pdf 10k
doc 34k
 
MS-5 Continuation Sheet pdf 10k
doc 36k
 
NA-4 Application for Approval of a Certified Medication Aide Training and Competency Evaluation Program (MATCEP) in Assisted Living Residences / Assisted Living Programs / Comprehensive Personal Care Homes pdf 13k
doc 52k
 
NA-8 Application for Approval of a Nurse Aide in Long Term Care Facilities Training and Competency Evaluation Program (NATCEP) pdf 16k
doc 53k
 
NA-11 Addendum: CMA Training - List of Course Attendees pdf 14k
doc 60k
 
NH-1 Application for Nursing Home Administrator License pdf 19k
doc 65k
 
NH-6 Verification of Out-of-State Licensure Status pdf 13k
doc 35k
 
NH-8 Application for Approval of Administrative Intern Program pdf 13k
doc 37k
 
NH-9 Quarterly Progress Report for Administrative Intern Program pdf 16k
doc 55k
 
NH-10 Certification of Program Completion for Nursing Home Administrative Intern Program pdf 13k
doc 41k
 
OC-18 Request for Meeting with Commissioner pdf 25k
doc 299k
 
OC-19 Commissioner Event Attendance Request pdf 23k
doc 228k
 
OC-24 Office of Minority and Multicultural Health "Health Equity for All" 2012 Calendar pdf 34k
doc 313k
 
OC-34 Government Records Request (OPRA) pdf 21k
doc 42k
 
OC-37 Institutional Approval of Intramural Research pdf 9k
doc 36k
 
OC-40 IRB Submission Checklist pdf 13k
doc 29k
 
OC-41 Agreement for Ethical Conduct of Human Subjects Research pdf 31k
doc 101k
 
OC-45 Agreement for Ethical Conduct of Human Subjects Research (Federal Employees) pdf 20k
doc 48k
 
OC-51 Notice of Claim of Exemption of Tobacco Retail Establishment pdf 35k
doc 85k
 
OC-53 Application for Registration of Exempt Cigar Bar or Lounge pdf 42k
doc 93k
 
OC-54 Application for Renewal of Registration of Exempt Cigar Bar or Lounge pdf 49k
doc 95k
 
OC-56 NJ Smoke Free Air Act / Complaint pdf 16k
doc 49k
 
OC-58 NJ Smoke Free Air Act / Anonymous Request for Investigation pdf 13k
doc 33k
 
OC-59 Notice - Smoke Free Air Act pdf 22k
doc 745k
 
OCC Right to Know Survey Forms  
 
 
OCC-1 Sharps Injury Log pdf 8k
doc 8k
 
OCC-2 Exposure Incident Report pdf 10k
doc 45k
 
OCC-3 Request for Source Individual Evaluation pdf 11k
doc 38k
 
OCC-4 Employee Exposure Determination pdf 8k
doc 31k
 
OCC-5 Employee Exposure Follow up Record pdf 8k
doc 35k
 
OCC-6 Hepatitis B Vaccine Immunization Record pdf 7k
doc 32k
 
OCC-8 Hepatitis B Declination Statement pdf 7k
doc 24k
 
OCC-9 Employee Education and Training Record pdf 11k
doc 31k
 
OCC-12 Public Employees Occupational Safety and Health (PEOSH) Unit Request for On-Site Consultation pdf 20k
doc 54k
On-Line Form  
OCC-15 Cleaning Schedule pdf 7k
doc 26k
 
OCC-16 EMS Respiratory Protection Program Evaluation Questionnaire pdf 11k
doc 41k
 
OCC-22 Documentation of Respirator Training pdf 7k
doc 25k
 
OCC-23 PEOSH Respirator Medical Evaluation Questionnaire pdf 32k
doc 158k
 
OCC-24 Firefighter Respirator Medical Evaluation Questionnaire pdf 34k
doc 162k
 
OCC-25 Documentation of Medical Evaluation for Respirator Use pdf 8k
doc 29k
 
OCC-30 Firefighter Respirator Fit Test Record pdf 11k
doc 30k
 
OCC-31 Occupational and Environmental Disease, Injury, or Poisoning Report by Health Care Provider pdf 29k
doc 64k
 
OCC-32 EMS Responder Fit Test Record pdf 7k
doc 29k
 
OCC-33 Firefighter SCBA After Use/Daily Inspection Checklist pdf 13k
doc 89k
 
OCC-34 Clinical Laboratory Report of Elevated Levels of Heavy Metals:Lead: In Adults (Greater than 16 Years of Age)Arsenic, Cadmium, Mercury: In Persons of Any Age pdf 15k
doc 48k
 
OCC-37 PEOSH Hazard Communication Standard, Documentation of Training pdf 10k
doc 43k
 
OCC-38 PEOSH Hazard Communication Standard
HazCom Compliance Checklist
pdf 24k
doc 95k
 
OCC-40 Worksheet for Hazardous Chemical List pdf 10k
doc 45k
 
OCC-41 Sample Letter for Requesting Material Safety Data Sheets (MSDS's) pdf 7k
doc 21k
 
OCC-46 Worker and Community Right to Know Act / Employer Outreach Survey pdf 14k
doc 75k
 
OCC-54 Quarterly Report of RTK County Lead Agencies pdf 12k
doc 47k
 
OCC-57 Public Employees Occupational Safety and Health (PEOSH) Unit Complaint pdf 16k
doc 51k
 
OTC-1 American Cancer Society (ACS) Monthly Activity Report pdf 47k
doc 262k
 
OTC-2 GASP Monthly Activity Report pdf 41k
doc 256k
 
OTC-3 Mom's Quit Connection (MQC) Monthly Activity Report pdf 32k
doc 221k
 
OTC-4 Regional Grantee Monthly Activity Report pdf 36k
doc 299k
 
PHSS-1 Application for Tanning Facilities Registration pdf 22k
doc 80k
 
PHSS-2 Warning Statement and Tanning Authorization pdf 27k
doc 36k
 
PHSS-3 Tanning Facility Inspection Checklist pdf 31k
doc 56k
 
PHSS-4 Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects (FY 2013) pdf 8k
doc 8kk
 
PHSS-4 Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects (FY2014) pdf 8k
doc 29k
 
PHSS-5 Payment Voucher, Tanning Facility Inspections (FY 2013) pdf 37k
doc 59k
Instructions for Completing the PHSS-5 Payment Voucher
pdf 9k
doc 23k  
PHSS-5 Payment Voucher, Tanning Facility Inspections (FY 2014) pdf 31k
doc 58k
Instructions for Completing the PHSS-5 Payment Voucher
pdf 9k
doc 23k  
PHSS-6 Confidential Medical Waste Exposure Report pdf 22k
doc 57k
 
PV 6-93 Payment Voucher pdf 38k
doc 65k
Instructions
pdf 8k
doc 20k  
RAD-4 Radioanalytical Services Sample Submittal pdf 20k
doc 86k
 
REG-1 Quarterly Report of Domestic Partnerships Registered
(Updated March, 2014)
pdf 14k
doc 39k
 
REG-2 Delegation of Authority to Receive Certified Copy of Vital Record (Birth/Death) pdf 14k
doc 31k
 
REG-3 Delegation of Authority to Receive Certified Copy
(Marriage/Civil Union)
pdf 14k
doc 32k
 
REG-4 Module 1, Birth Certificate Worksheet, Prenatal Information pdf 23k
doc 69k
 
REG-4 Module 2, Birth Certificate Worksheet, Labor and Delivery pdf 106k
doc 49k
 
REG-4 Module 3, Birth Certificate Worksheet, Newborn Delivery pdf 61k
doc 79k
 
REG-4 Module 4, Birth Certificate Worksheet, Parent Information Module pdf 26k
doc 98k
 
REG-4 Module 5, Birth Certificate Worksheet, Newborn Discharge Module(Legal-Sized Format) pdf 38k
doc 71k
 
REG-4 Module 5, Birth Certificate Worksheet, Newborn Discharge Module (Letter-Sized Format) pdf 40k
doc 90k
 
REG-4 Module 6, Birth Certificate Worksheet, Parent /Guardian Module pdf 19k
doc 44k
 
REG-4 Module 7, Birth Certificate Worksheet, Mother's Discharge Information pdf 72k
doc 37k
 
REG-4A Module 4, Birth Certificate Worksheet, Parent Information Module (Spanish)(Legal-Sized Format) pdf 69k
doc 99k
 
REG-4A Module 4, Birth Certificate Worksheet, Parent Information Module (Spanish)(Letter-Sized Format) pdf 102k
doc 99k
 
REG-5 Report of No Births, Marriages, Civil Unions, Domestic Partnerships, Fetal Deaths or Deaths
(Updated July, 2012)
pdf 17k
doc 26k
 
REG-7E Application for a Certified Copy of a "No Record of Marriage" Statement (English/Spanish) pdf 22k
doc 119k
 
REG-10 Module 3, Fetal Death Certificate Worksheet, Delivery Module pdf 96k
doc 89k
 
REG-10A Module 4, Fetal Death Certificate Worksheet, Parent Information Module (Spanish) (Legal-Sized Format) pdf 81k
doc 98k
 
REG-10A Module 4, Fetal Death Certificate Worksheet, Parent Information Module (Spanish) (Letter-Sized Format) pdf 87k
doc 100k
 
REG-10 Module 4, Fetal Death Certificate Worksheet, Parent Information Module pdf 30k
doc 97k
 
REG-13 Certified Municipal Registrar Recertification Course Tracking Log
(Updated July, 2012)
pdf 10k
doc 46k
 
REG-20 Authorization for Release of Cause of Death
Autorización para la Emision de Causa de Muerte
(Combined English and español)
pdf 18k
doc 38k
 
REG-24X Template for Electronic Marriage License and Certificate
(Updated 1/24/14)
 
doc 54k
 
REG-25 Notification of Marriage/Civil Union
(Updated October, 2013)
pdf 11k
doc 27k
 
REG-27 Application for a Non-Genealogical Certification or Certified Copy of a Vital Record
Aplicación Para Copias Certificadas ó Certificaciones de Registros Civiles No-Ancestro
(Combined English/español)
(Updated January, 2014)
pdf 52k
doc 56k
English Instructions (REG-27A)
pdf 22k
doc 40k

Español Instrucciones (REG-27B)
pdf 22k
doc 46k  
REG-28 Application for a Genealogical Certification or Certified Copy of a Vital Record
Aplicación Para Copias Certificadas ó Certificaciones de Registros Civiles Ancestro
(Combined English/español)
pdf 51k
doc 52k
English Instructions (REG-28A)
pdf 20k
doc 38k

español Insturcciones (REG-28B)
pdf 20k
doc 42k  
REG-31 Consent of Parents or Guardian to Marriage or Civil Union of Minor
Consentimiento Paterno ó de Guardian Legal para Matrimonio o Unión Civil de un Menor
(Combined English/español)
pdf 89k
doc 50k
 
REG-34 Request for Correction to NJ Vital Record of Birth, Death, Fetal Death, Marriage, Civil Union, Domestic Partnership pdf 23k
doc 56k
 
REG-35 Correcting a Birth Record for Child Whose Natural Parents Married After Its Birth pdf 17k
doc 42k
 
REG-37 Application for Non-Genealogical Certification or Certified Copy of a Vital Record (Local Use)
(Updated February, 2014)
pdf 52k
doc 57k
 
REG-38 Application for Genealogical Certification or Certified Copy of a Vital Record (Local Use) pdf 60k
doc 52k
 
REG-42D(1) Birth Template (One Parent)
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
 
doc 28k
 
REG-42D(2) Birth Template (Parent, Parent)
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
 
doc 29k
 
REG-42E Birth Template (No Parent Names)
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
 
doc 28k
 
REG-42F(1) Marriage Template (long form with Parents' Names)
for use on REG-42A Certified Copy Paper
(Updated November, 2013)
 
doc 30k
 
REG-42F(2) Marriage Template (short form without Parents' Names)
for use on REG-42A Certified Copy Paper
(Updated November, 2013)
 
doc 28k
 
REG-42G Death Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
 
doc 30k
 
REG-42H Domestic Partnership Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
 
doc 29k
 
REG-42I (1) Civil Union Template (without Parent Names)
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
 
doc 27k
 
REG-42I(2) Civil Union Template (with Parent Names)
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
 
doc 31k
 
REG-42J Remarriage Template
for use on REG-42A Certified Copy Paper
(Updated October, 2013)
 
doc 29k
 
REG-42K Reaffirmation of Civil Union Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
 
doc 29k
 
REG-44 Report of Adoption
Registrar una Adopción
pdf 16k
doc 43k
English Instructions

español Instrucciones  
REG-45 Request for Legal Name Change to Original Record of Birth, Marriage, Civil Union or Domestic Partnership pdf 29k
doc 42k
 
REG-56 Correcting a Birth Record for Out-of-Wedlock Child Whose Mother Married a Man Other Than the Natural Father pdf 16k
doc 41k
 
REG-60 Correcting the Birth Record of a Child Said to Have Been Born Out-of-Wedlock and Whose Natural Parents Have Not Married Each Other pdf 19k
doc 43k
 
REG-62 Request to Purchase Certified Copy of Vital Records Forms
(Updated March 18, 2014)
pdf 25k
doc 40k
 
REG-66 Log of Voided Certified Copy Forms pdf 10k
doc 57k
 
REG-68 Request to Place on File a Certificate of Birth Resulting in Stillbirth
Solicitud para Archivar un Registro de Partida de Nacimiento Resultando en Parto Muerto
pdf 14k
doc 36k
Guidelines (Guia), (English/español) (REG-D34)
pdf 31k
doc 37k  
REG-69 Quarterly Report of Non-EDRS Burial Permits Issued
(Updated March, 2014)
pdf 14k
doc 39k
 
REG-77 Application for Marriage, Remarriage, Civil Union, or Reaffirmation of Civil Union
Aplicación para Licencia: Matrimonio, Unión Civil, Rematrimonio, y Reafirmación de Unión Civil
pdf 24k
doc 95k
 
REG-D7 Notice of Rights and Obligations of Domestic Partners pdf 21k
doc 38k
 
REG-D7A Notice of Rights and Obligations of Domestic Partners (Spanish) pdf 25k
doc 43k
 
REG-D30 "Entering into a Marriage or Civil Union in New Jersey" Brochure pdf 14k
doc 31k
 
REG-D30A "Entering into a Marriage or Civil Union in New Jersey" Brochure (español) pdf 24k
doc 47k
 
REG-D30B Entering into a Marriage or Civil Union in New Jersey Brochure (Russian) pdf 157k
doc 39k
 
REG-D30C Entering into a Marriage or Civil Union in New Jersey Brochure (Korean) pdf 118k
doc 47k
 
REG-D33 "Registering a Domestic Partnership in New Jersey" Brochure pdf 15k
doc 30k
 
REG-D33A "Registering a Domestic Partnership in New Jersey" Brochure (español) pdf 23k
doc 47k
 
REG-D33B Registering a Domestic Partnership in New Jersey (Russian) pdf 121k
doc 41k
 
REG-D33C Registering a Domestic Partnership in New Jersey (Korean) pdf 120k
doc 49k
 
REG-D34 Guidelines for Requesting to Place on File a Certificate of Birth Resulting in Stillbirth (English/español) pdf 31k
doc 44k
 
RTK-2012 2012 RTK Complete Survey Forms  
 
 
SCH-0 Special Child Health Services Registration Form pdf 26k
doc 130k
Instructions and Legends
pdf 28k
doc 53k  
SCH-1 Autism Supplemental Information pdf 18k
doc 77k
Instructions
pdf 25k
doc 46k  
SCH-2 Newborn Hearing Follow-Up Report pdf 31k
doc 77k
Instructions
pdf 21k
doc 32k  
SCH-3 Lost to Hearing Follow Up Report pdf 25k
doc 63k
 
SCH-6 Critical Congenital Heart Defects Screening Program
Aggregate Report
 
doc 35k
 
SCH-7 Notice of Availability of Supplemental Newborn Screening pdf 30k
doc 72k
 
SCH-7A Notice of Availability of Supplemental Newborn Screening (spanish) pdf 35k
doc 77k
 
SCH-13 Request for Hearing Aids pdf 29k
doc 56k
 
SCR Online Spinal Cord Research Grant Applications  
 
 
SRD-1 Request for Immunological/Isolation Services-Viral Testing Unit pdf 23k
doc 57k
 
SRD-4 Request for Immunological/Isolation Services - Clinical Services Testing Unit pdf 25k
doc 52k
 
STD-11 Confidential Sexually Transmitted Disease Report pdf 38k
doc 72k
 
TB-1 Quarterly Chest Clinic Activity Report pdf 9k
doc 31k
 
TB-3 Medication Request Order pdf 14k
doc 96k
 
TB-4 TB Field Referral pdf 12k
doc 40k
 
TB-5 Symptom Assessment for Pulmonary Tuberculosis (TB) pdf 8k
doc 29k
 
TB-8 Religious Exemption - School TB Testing/Symptom Assessment Form pdf 9k
doc 30k
 
TB-9 Statement of Non-Infectiousness for Symptomatic Individual pdf 9k
doc 27k
 
TB-10 Statement of Non-Infectiousness for Individual with TB Disease pdf 9k
doc 27k
 
TB-41 Record of Contact Interview (Original + 1 Continuation Page) pdf 23k
doc 147k
Instructions
pdf 20k
doc 42k  
TB-41 Record of Contact Interview (Original + 2 Continuation Pages) pdf 30k
doc 224k
Instructions
pdf 20k
doc 42k  
TB-41 Record of Contact Interview (Original + 5 Continuation Pages) pdf 51k
doc 445k
Instructions
pdf 20k
doc 42k  
TB-43 Tuberculosis (TB) Testing Survey Results pdf 13k
doc 98k
Instructions
pdf 9k
doc 22k  
TB-57 Annual Report of TB Testing in Schools pdf 13k
doc 41k
Instructions
pdf 21k
doc 24k  
VAERS Vaccine Adverse Event Reporting System: Online  
 
 
VIR-1 Requisition for Viral Serology pdf 22k
doc 39k
Complete per instructions on form  
VIR-16 Request for Rabies Examination pdf 14k
doc 59k
Directions/Map to DHSS Lab

Instructions for submission of specimens
pdf 19k
doc 41k  
VPH-1 Inspection Report of Kennels, Pet Shops, Shelters, and Pounds pdf 16k
doc 66k
 
VPH-2 Animal Rescue Organization Registration pdf 14k
doc 36k
 
VPH-3 List of Licensed Kennels, Pet Shops, Shelters and Pounds pdf 20k
doc 41k
Instructions
pdf 9k
doc 22k  
VPH-7 Report of Census of Unlicensed Dogs pdf 12k
doc 46k
Instructions
pdf 9k
doc 21k  
VPH-10 Monthly Dog License Report pdf 13k
doc 39k
Instructions
pdf 12k
doc 28k  
VPH-11 Notice of Animal Bite and Confinement pdf 14k
doc 36k
Instructions
pdf 11k
doc 25k  
VPH-20 Certification of Veterinary Supervision pdf 9k
doc 28k
 
VPH-23 Notice of Intent, State/Municipal-Sponsored Rabies Vaccination Clinics pdf 11k
doc 32k
Instructions for State/Municipal Sponsored Rabies Vaccination Clinics (VPH-23 and VPH-25)
pdf 10k
doc 22k  
VPH-25 State/Municipal-Sponsored Rabies Vaccination Clinic Report pdf 9k
doc 27k
Instructions for State/Municipal Sponsored Rabies Vaccination Clinics (VPH-23 and VPH-25)
pdf 10k
doc 22k  
VPH-26 Rabies Vaccination Certificate pdf 12k
doc 36k
 
VPH-28 Certificate of Exemption from Rabies Vaccination pdf 21k
doc 38k
 
VPH-30 Application for Animal Cruelty Investigator Certification pdf 10k
doc 28k
 
VPH-32 Application for Animal Control Officer Certification pdf 10k
doc 28k
 
W-9 Vendor Questionnaire pdf 37k
doc 70k
Instructions
pdf 13k
doc 22k  
WIC-9 Medical Documentation for Milk Substitutes
(NOTE: Effective October 1, 2009)
pdf 22k
doc 54k
 
WIC-11 Medical Documentation for WIC Formula and Approved WIC Foods for Infants, Children and Women pdf 26k
doc 70k
 
WIC-12 Designation of Infant Formula Manufacturer, Retailer, Wholesaler and Distributor pdf 12k
doc 29k
 
WIC-41 NJ WIC Health Care Referral (Women) pdf 26k
doc 79k
 
WIC-42 NJ WIC Health Care Referral (Infants and Children) pdf 25k
doc 70k