Forms for Health Professionals
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| CDC-2 |
Report of Rabies Postexposure Treatment |
pdf 21k
doc 59k |
|
| CDS-1 |
For Reporting Reportable Communicable Diseases |
pdf 74k
doc 98k |
|
| CDS-2 |
Request for Human WestNile Virus Testing - Patient Intake Form |
pdf 75k
doc 96k |
|
| CDS-4 |
Dead-Ill Bird Report/Lab Submission Form |
pdf 82k
doc 41k |
|
| 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 25k
doc 47k |
|
| CDS-10 |
Kawasaki Syndrome Disease Report |
pdf 18k
doc 44k |
|
| CDS-11 |
Patient Symptoms Line Listing (Respiratory Tract Infection) |
pdf 32k
doc 32k |
|
| CDS-12 |
Patient Symptoms Line Listing (Gastrointestinal Infection) |
pdf 44k
doc 42k |
|
| CDS-13 |
Food-Specific Attack Rate Worksheet |
pdf 25k
doc 31k |
|
| CDS-14 |
Lyme Disease Case Investigation |
pdf 49k
doc 45k |
|
| CDS-15 |
Hemolytic Uremic Syndrome (Postdiarrheal) Report |
pdf 25k
doc 41k |
|
| CDS-16 |
Epidemiology Surveillance Record (Hospital-Based Laboratory) |
pdf 13k
doc 93k |
|
| CDS-17 |
Hepatitis C Report |
pdf 15k
doc 51k |
|
| 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 82k
doc 102k |
Guidelines
pdf 30k
doc 32k
|
| CDS-25 |
Avian Influenza Screening Information |
pdf 19k
doc 66k |
|
| CDS-26 |
Speakers' Bureau Request |
pdf 10k
doc 30k |
|
| CDS-28 |
Gastrointestinal/Foodborne Illness Case Report |
pdf 28k
doc 102k |
|
| CDS-29 |
Salmonella / STEC (including E. coli O157:H7) Questionnaire |
pdf 41k
doc 257k |
|
| CDS-30 |
Outbreak Report for Long Term Care and Other Institutions |
pdf 27k
doc 143k |
Instructions for Completing the CDS-30
pdf 20k
doc 27k
|
| CDS-L2 |
Hepatitis B Reporting Letter |
pdf 31k
doc 766k |
|
| VIR-16 |
Request for Rabies Examination |
pdf 48k
doc 60k |
Directions and Map to DHSS Lab
pdf 13k
doc 24k
Directions and Map to DHSS Lab
Instructions for submission of specimens
pdf 23k
doc 27k
|
Vaccine Preventable Disease Program
Reporting Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| IMM-3 |
Annual College Immunization Status Report |
pdf 18k
doc 55k |
|
| IMM-4 |
Annual Hospital Employee Rubella and Measles Immunity Status Report |
pdf 13k
doc 43k |
|
| IMM-5 |
Varicella Case Report |
pdf 24k
doc 106k |
|
| IMM-6 |
Vaccine Usage Report |
pdf 12k
doc 32k |
|
| IMM-7 |
Annual Immunization Status Report |
|
Instructions
pdf 137k
Notes
|
| IMM-10 |
Rubella Surveillance Worksheet |
pdf 39k
doc 124k |
|
| IMM-11 |
Measles Surveillance Worksheet |
pdf 36k
doc 113k |
|
| IMM-12 |
Retrospective Immunization Audit / Survey |
pdf 14k
doc 114k |
|
| IMM-14 |
Immunization Audit Report Worksheet |
pdf 17k
doc 189k |
|
| IMM-15 |
Immunization Audit Report |
pdf 24k
doc 50k |
|
| IMM-17 |
Vaccine Order (For Ages 19 and Above Only |
pdf 30k
doc 71k |
|
| IMM-18 |
Provider Profile: Adults/Adolescents |
pdf 18k
doc 53k |
|
| IMM-20 |
Confidential Perinatal Hepatitis-B Case and Contact Report |
pdf 26k
doc 134k |
Instructions for Completing the imm-20 Form
pdf 13k
doc 23k
|
| IMM-21 |
Mumps Surveillance Worksheet |
pdf 35k
doc 145k |
|
| IMM-22 |
Tetanus Surveillance Worksheet |
pdf 28k
doc 95k |
|
| IMM-24 |
Pertussis Investigation Record |
pdf 30k
doc 183k |
|
| 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 22k
doc 27k |
|
| IMM-19A-MEMO |
Consent to Participate-NJIIS - Schools (Side 1, Memo) (Spanish) |
pdf 10k
doc 24k |
|
| IMM-19-FORM |
Consent to Participate-NJIIS - Schools (Side 2, Form) (English) |
pdf 18k
doc 25k |
|
| IMM-19-MEMO |
Consent to Participate-NJIIS - Schools (Side 1, Memo) (English) |
pdf 9k
doc 21k |
|
| IMM-25 |
Vaccines for Children Program / Provider Enrollment |
pdf 21k
doc 40k |
|
| IMM-26 |
Provider Profile |
pdf 18k
doc 54k |
|
| IMM-26A |
Additional Enrollment for Other Providers within the Practice |
pdf 12k
doc 34k |
|
| IMM-27 |
Vaccine Order for Birth through 18 Years and Adolescent Clinics |
pdf 26k
doc 72k |
|
| IMM-28 |
Eligibility/Vaccine Encounter Record |
pdf 18k
doc 48k |
|
| IMM-29 |
Request for Change of User Security Authorization/ Request for Password Reset |
pdf 24k
doc 35k |
|
| IMM-30 |
Vaccines for Children Program / Provider Disenrollment Request |
pdf 14k
doc 54k |
|
| IMM-32 |
NJIIS Consent to Participate (English) |
pdf 30k
doc 30k |
|
| IMM-32A |
NJIIS Consent to Participate (Spanish) |
|
|
| IMM-33 |
Varicella/MMRV Storage Questionnaire |
pdf 14k
doc 38k |
|
| 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-39 |
Vaccine Return Voucher |
pdf 14k
doc 67k |
|
| 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 52k
doc 45k |
|
| APC-7 |
Payment Voucher / Veterinarian Reimbursement |
pdf 28k
doc 883k |
|
| APC-8 |
Supply Requisition, Low Cost Spaying and Neutering Program |
pdf 39k
doc 30k |
|
| APC-11 |
Animal Population Control Program Proxy Authorization |
pdf 49k
doc 33k |
|
| VPH-30 |
Application for Animal Cruelty Investigator Certification |
pdf 21k
doc 27k |
|
| VPH-32 |
Application for Animal Control Officer Certification |
pdf 21k
doc 27k |
|
Shelter/Pound Survey Form
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| APC-12 |
Shelter/Pound Survey of Stray Animal Intake and Disposition |
pdf 12k
doc 75k |
|
Animal Licensing and Confinement Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| VPH-3 |
List of Licensed Kennels, Pet Shops, Shelters and Pounds |
pdf 44k
doc 56k |
Instructions
pdf56k
doc20k
|
| VPH-7 |
Report of Census of Unlicensed Dogs |
pdf 56k
doc 48k |
Instructions
doc20k
|
| VPH-10 |
Monthly Dog License Report |
pdf 76k
doc 40k |
Instructions
doc27k
|
| VPH-11 |
Notice of Animal Bite and Confinement |
pdf 76k
doc 36k |
Instructions
pdf24k
|
Animal Control and Faciility Inspection
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| VPH-1 |
Inspection Report of Kennels, Pet Shops, Shelters, and Pounds |
pdf 16k
doc 67k |
|
| VPH-20 |
Certification of Veterinary Supervision |
pdf 41k
doc 27k |
|
State/Municipal-Sponsored Rabies Vaccination
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| VPH-23 |
Notice of Intent, State/Municipal-Sponsored Rabies Vaccination Clinics |
pdf 28k
doc 32k |
|
| VPH-25 |
State/Municipal-Sponsored Rabies Vaccination Clinic Report |
pdf 44k
doc 28k |
|
| VPH-26 |
Rabies Vaccination Certificate |
pdf 76k
doc 40k |
|
| VPH-28 |
Certificate of Exemption from Rabies Vaccination |
pdf 21k
doc 38k |
|
Sexually Transmitted Diseases
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| STD-11 |
Confidential Sexually Transmitted Disease Report |
pdf 64k
doc 70k |
|
Tuberculosis Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| TB-1 |
Quarterly Chest Clinic Activity Report |
pdf 10k
doc 30k |
|
| TB-4 |
TB Field Referral |
pdf 12k
doc 40k |
|
| TB-7 |
Change in School Information |
pdf 12k
doc 34k |
|
| TB-41 |
Record of Contact Interview (Original + 1 Continuation Page) |
pdf 26k
doc 152k |
Instructions
pdf 20k
doc 42k
|
| TB-41 |
Record of Contact Interview (Original + 2 Continuation Pages) |
pdf 35k
doc 231k |
Instructions
pdf 20k
doc 42k
|
| TB-41 |
Record of Contact Interview (Original + 5 Continuation Pages) |
pdf 64k
doc 462k |
Instructions
pdf 20k
doc 42k
|
| TB-57 |
Annual Report of TB Testing in Schools |
pdf 13k
doc 42k |
Instructions
pdf 21k
doc 22k
|
DHSS Forms
