CDC Report Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| CDC-2 |
Report of Rabies Postexposure Treatment |
pdf 16k
doc 58k |
|
| 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 |
|
|
| IMM-PKG-A |
Provider Reenrollment Package (Adult) |
pdf 29k
doc 112k |
|
Forms for Health Professionals
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| 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 for Completing the CDS-30
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-L2 |
Hepatitis B Reporting Letter |
pdf 31k
doc 767k |
|
| VIR-16 |
Request for Rabies Examination |
pdf 14k
doc 59k |
Directions/Map to DHSS Lab
Instructions for submission of specimens
pdf 16k
doc 27k
|
Vaccine Preventable Disease Program
Reporting Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| 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 |
Vaccine Usage Report |
pdf 11k
doc 30k |
|
| IMM-7 |
Annual Immunization Status Report |
|
|
| IMM-8 |
Standard School/Child Care Center Immunization Record |
|
To request this form, please contact the VPDP Program at 609-826-4861.
|
| IMM-9 |
Personal Immunization Record |
|
To request this form, please contact the VPDP 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-14 |
Immunization Audit Report Worksheet |
pdf 17k
doc 193k |
|
| IMM-15 |
Immunization Audit Report |
pdf 24k
doc 51k |
|
| IMM-17 |
Vaccine Order (Adult Vaccine Program)
Click HERE for information about faxed vaccine orders. |
|
|
| IMM-18 |
Provider Profile: Adults |
pdf 17k
doc 53k |
|
| 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-PKG-A |
Provider Reenrollment Package (Adult) |
pdf 29k
doc 112k |
|
| IMM-PKG-P |
Provider Reenrollment Package (Pediatric) |
pdf 30k
doc 123k |
|
| VAERS-1 |
Vaccine Adverse Event Reporting System |
pdf 246k
|
|
NJ Immunization Information System
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| 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-25 |
Vaccines for Children Program / Provider Enrollment |
pdf 14k
doc 36k |
|
| IMM-26 |
Provider Profile (Pediatrics) |
pdf 18k
doc 62k |
|
| IMM-26A |
Licensed Medical Providers List |
pdf 13k
doc 39k |
|
| IMM-27 |
Vaccine Order (Vaccine for Children Program)
Click HERE for information about faxed vaccine orders. |
pdf 26k
doc 71k |
|
| IMM-28 |
Eligibility/Vaccine Encounter Record |
pdf 18k
doc 45k |
|
| IMM-29 |
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-32 |
NJIIS Consent to Participate (English) |
pdf 12k
doc 30k |
|
| IMM-33 |
Varicella/MMRV Storage Questionnaire |
pdf 12k
doc 37k |
|
| IMM-34 |
Site Enrollment Request: Early Hearing Detection and Intervention Program |
pdf 18k
doc 32k |
|
| IMM-35 |
User Enrollment and Training Request: Early Hearing Detection and Intervention Program |
pdf 10k
doc 30k |
|
| IMM-40 |
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 20k
doc 41k |
Instructions
pdf 13k
doc 25k
|
| IMM-43 |
User Confidentiality Statement for Access to NJIIS/ User Confidentiality Agreement |
pdf 14k
doc 32k |
|
| IMM-44 |
Declination of Newborn Automatic Enrollment |
pdf 10k
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 |
|
Animal Population Control Program
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| APC-5 |
Application and Consent for Sterilization of Pets |
pdf 15k
doc 44k |
|
| APC-7 |
Payment Voucher / Veterinarian Reimbursement |
pdf 28k
doc 3063k |
|
| APC-11 |
Animal Population Control Program Proxy Authorization |
pdf 11k
doc 33k |
|
| VPH-30 |
Application for Animal Cruelty Investigator Certification |
pdf 10k
doc 28k |
|
| VPH-32 |
Application for Animal Control Officer Certification |
pdf 10k
doc 28k |
|
Shelter/Pound Survey Form
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| APC-12 |
Shelter/Pound Annual Report |
pdf 13k
doc 91k |
Instructions
pdf 13k
doc 32k
|
Animal Licensing and Confinement Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| 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
|
Animal Control and Facility Inspection
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| VPH-1 |
Inspection Report of Kennels, Pet Shops, Shelters, and Pounds |
pdf 16k
doc 66k |
|
| VPH-2 |
Animal Rescue Organization Registration |
pdf 16k
doc 37k |
|
| VPH-20 |
Certification of Veterinary Supervision |
pdf 9k
doc 28k |
|
State/Municipal-Sponsored Rabies Vaccination
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| 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 |
|
