DOH Forms
Additional Health Department Forms

Forms for Communicable Disease Service


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 19k
doc 41k  

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 New Provider Profile: Adults pdf 15k
doc 55k
 
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
New Provider Enrollment
pdf 14k
doc 34k
 
IMM-26 New Provider Profile (Pediatrics) pdf 15k
doc 63k
 
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-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-38 Influenza Vaccine Order (2013-2014)
Vaccines for Children Program
pdf 12k
doc 37k
 
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 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 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
 

Animal Population Control Program
Form # Title PDF/WORD Instruction/ Comments
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 2014)
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
 
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
 
Go to Communicable Disease Service     Additional Health Department Forms