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-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-37 Certification by Physician (ADDP/HICP) pdf 13k
doc 41k
 
DHAS-39 Health Insurance Information
Health Insurance Continuation Program (HICP)
pdf 13k
doc 51k
 

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
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
 
 
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)
 
 
 

Tuberculosis Forms
Form # Title PDF/WORD Instruction/ Comments
LAB-10 Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT)
pdf 14k
doc 49k
 
TB-1 Quarterly Chest Clinic Activity Report pdf 9k
doc 31k
 
TB-3 Medication Request Order pdf 14k
doc 96k
Medication Request Order Instructions
pdf 448k  
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  

Sexually Transmitted Diseases
Form # Title PDF/WORD Instruction/ Comments
STD-11 Confidential Sexually Transmitted Disease Report pdf 38k
doc 72k
 

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