NJ Home | Services A to Z | Departments/Agencies | FAQs
Search
DOH Forms
Additional Health Department Forms

Forms for HIV/AIDS, STD and TB Services


Health Insurance Continuation Program
Form # Title PDF/WORD Instruction/ Comments
DHAS-34 Renewal Application for Participation in the Health Insurance Continuation Program pdf 25k
doc 72k		  
DHAS-39 Health Insurance Information pdf 19k
doc 50k		  
DHAS-41 Authorization/Release of Information pdf 14k
doc 31k		  
DHAS-42 Confidentiality Release pdf 14k
doc 29k		  

HIV Consent Forms
Form # Title PDF/WORD Instruction/ Comments
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		  

Home Health Program
Form # Title PDF/WORD Instruction/ Comments
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		  

Grant Forms
Form # Title PDF/WORD Instruction/ Comments
DHAS-1 Grant Application Checklist pdf 65k
doc 65k		  
DHAS-2 Fringe Benefit Breakdown pdf 7k
doc 26k		  
DHAS-35 Title II Reports  
 		 excel 1.51mb  

Case Reporting
Form # Title PDF/WORD Instruction/ Comments
DHAS-43 Confidential Laboratory Report pdf 16k
 		  
DHAS-44 Adult HIV/AIDS Confidential Care Report pdf 41k
doc 139k		  
DHAS-45 Pediatric HIV/AIDS Confidential Case Report pdf 47k
doc 175k		  

Tuberculosis Forms
Form # Title PDF/WORD Instruction/ Comments
TB-1 Quarterly Chest Clinic Activity Report pdf 10k
doc 31k		  
TB-3 Medication Request Order pdf 15k
doc 88k		  
TB-4 TB Field Referral pdf 12k
doc 40k		  
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 26k
doc 147k		 Instructions
pdf 20k
doc 42k  
TB-41 Record of Contact Interview (Original + 2 Continuation Pages) pdf 35k
doc 223k		 Instructions
pdf 20k
doc 42k  
TB-41 Record of Contact Interview (Original + 5 Continuation Pages) pdf 64k
doc 447k		 Instructions
pdf 20k
doc 42k  
TB-57 Annual Report of TB Testing in Schools pdf 13k
doc 41k		 Instructions for Completing the TB-57 Form
pdf 21k
doc 24k  

Sexually Transmitted Diseases
Form # Title PDF/WORD Instruction/ Comments
STD-11 Confidential Sexually Transmitted Disease Report pdf 36k
doc 70k		  

Other
Form # Title PDF/WORD Instruction/ Comments
CT-11 Records Release Authorization pdf 23k
doc 134k		  
CT-11A Records Release Authorization (spanish) pdf 23k
doc 21k		  
Go to HIV/AIDS, STD and TB Services     Additional Health Department Forms