DOH Forms
Additional Health Department Forms

Forms for Health Care Quality Assessment


Stroke Services
Form # Title PDF/WORD Instruction/ Comments
HCQ-8 NJ Acute Stroke Registry pdf 48k
doc 207k
Instructions
pdf 409k  

Cardiac Services Data Registry
Form # Title PDF/WORD Instruction/ Comments
HCQ-7 Cardiac Cathereterization Data Registry pdf 88k
doc 251k
Instructions
pdf 1036k  
HCQ-9 Open Heart Surgery Risk Stratification Project - Data Collection Form, Version 4.1
(formerly HCQO-22)
pdf 31k
doc 79k
Instructions
pdf 710k  
HCQO-27 Quarterly Cardiac Data Submission Report pdf 12k
doc 37k
 

Hospital Patient Care Staffing
Form # Title PDF/WORD Instruction/ Comments
HCQ-3 Daily Patient Care Staffing: Inpatient Units pdf 17k
doc 54k
Instructions
pdf 13k
doc 24k  
HCQ-3A Daily Patient Care Staffing - Inpatient (Spanish) pdf 19k
doc 58k
Instructions
pdf 14k
doc 26k  
HCQ-4 Daily Patient Care Staffing: Emergency Department pdf 10k
doc 30k
Instructions
pdf 10k
doc 22k  
HCQ-4A Daily Patient Care Staffing - Emergency Department (Spanish) pdf 13k
doc 32k
Instructions
pdf 13k
doc 25k  
HCQ-5 Daily Patient Care Staffing: Post-Anesthesia Care Unit pdf 10k
doc 30k
Instructions
pdf 10k
doc 22k  
HCQ-5A Daily Patient Care Staffing - Post Anesthesia Care Unit (PACU) (Spanish) pdf 13k
doc 32k
Instructions
pdf 13k
doc 25k  
HCQ-6 Daily Patient Care Staffing-Other Licensed Health Care Professionals: Hospital-Wide pdf 10k
doc 28k
Instructions
pdf 10k
doc 22k  
HCQ-6A Daily Patient Care Staffing - Other Licensed Health Care Professionals, Hospital Wide (Spanish) pdf 11k
doc 29k
Instructions
pdf 11k
doc 25k  

Patient Safety Reporting System
Form # Title PDF/WORD Instruction/ Comments
HCQ-1 Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility (for use on or after January 1, 2007) (formerly HCQO-19) pdf 25k
doc 91k
 
HCQ-2 Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility - Root Cause Analysis (RCA) (for use on or after January 1, 2007) (formerly HCQO-20) pdf 19k
doc 62k
 
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