DOH Forms
Additional Health Department Forms

Forms for Division of Health Facilities Evaluation and Licensing


Ambulatory Care Assessment
Form # Title PDF/WORD Instruction/ Comments
HFEL-5 Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment pdf 10k
doc 34k
Instructions
pdf 8k
doc 22k  

Certificate of Need and Acute Care Licensure
Form # Title PDF/WORD Instruction/ Comments
CN-1 Full Review Certificate of Need Application for Long Term Care Facilities: General Long Term Care Beds; Specialized Long Term Care Beds pdf 85k
doc 440k
 
CN-3 Application for Certificate of Need for Hospital-Related Projects pdf 76k
doc 503k
 
CN-4 Application for Certificate of Need for Designation as a Perinatal Facility pdf 54k
doc 218k
 
CN-7 Application for New or Amended Acute Care Facility License pdf 55k
doc 294k
Fees for Licensure and Inspection  
CN-10 Annual Report of Megavoltage Radiation Unit pdf 17k
doc 60k
 
CN-19 Certificate of Need Application - Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a) pdf 35k
doc 118k
 
CN-28 Application for Waiver pdf 20k
doc 37k
 

Medication Aide/Nurse Aide Certification Program
Form # Title PDF/WORD Instruction/ Comments
NA-4 Application for Approval of a Certified Medication Aide Training and Competency Evaluation Program (MATCEP) in Assisted Living Residences / Assisted Living Programs / Comprehensive Personal Care Homes pdf 13k
doc 52k
 
NA-8 Application for Approval of a Nurse Aide in Long Term Care Facilities Training and Competency Evaluation Program (NATCEP) pdf 16k
doc 53k
 
NA-11 Addendum: CMA Training - List of Course Attendees pdf 14k
doc 60k
 

Long Term Care Forms and Publications
Form # Title PDF/WORD Instruction/ Comments
AAS-5 Facility Inspection Worksheet (Resident Rights, Physical Plant and Environment, Safety, Dietary Services) pdf 36k
doc 114k
 
AAS-11 Nurse Staffing Report pdf 11k
doc 54k
 
AAS-22 Adult Medical Day Care Inspection Information pdf 31k
doc 73k
 
AAS-23 Pediatric Medical Day Care Inspection Information pdf 25k
doc 62k
 
AAS-24 Affidavit of Compliance Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs pdf 19k
doc 72k
 
AAS-40 Affidavit of Compliance with N. J. Licensure Standards for Adult Day Health Care Facilities pdf 14k
doc 44k
 
AAS-45 Reportable Event Record/Report pdf 16k
doc 56k
 
AAS-55 Declaration of Compliance with Advisory Standards pdf 67k
doc 175k
 
AAS-59 Medical Day Inspection Information pdf 29k
doc 77k
 
AAS-60 Consumer Resident/Patient Complaint Report pdf 18k
doc 56k
 
AAS-61 Medical Day Care Assessment and Survey
Exit Conference Guide
pdf 12k
doc 47k
 
AAS-80 Assisted Living Assessment and Survey
Exit Conference Guide
pdf 13k
doc 48k
 
AAS-81 Assisted Living Entrance Guide pdf 8k
doc 23k
 
AAS-84 Affidavit of Compliance with N. J. Licensure Standards for Pediatric Medical Day Care Facilities pdf 14k
doc 38k
 
HFEL-3 Project Application for an Adult Day Health Services Facility pdf 18k
doc 43k
 
HFEL-4 Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility pdf 16k
doc 39k
 
HFEL-6 Resident Care Staffing Report pdf 10k
doc 29k
Instructions
pdf 12k
doc 23k  
HFEL-7 New Jersey Universal Transfer Form pdf 21k
doc 108k
Instructions
pdf 38k
doc 66k  
LCS-4 Communicable Disease Alert pdf 10k
doc 29k
 
LCS-5 Application for the Addition of Long Term Care Beds pdf 22k
doc 41k
 
LCS-8 Facility Reporting Incident Data and Analysis Yield (FRIDAY) pdf 51k
doc 125k
 
LCS-9 Application for a Long Term Care Facility License pdf 37k
doc 151k
 
LTC-2 Notification form Long-Term Care Facility of Admission or Termination of a Medicaid Beneficiary  
 
 
LTC-4 Hospital Preadmission Screening Referral  
 
 
LTC-19 Request for Billing Assistance  
 
 

Nursing Home Administrator Licensure and Licensing Board
Form # Title PDF/WORD Instruction/ Comments
NH-1 Application for Nursing Home Administrator License pdf 19k
doc 65k
 
NH-6 Verification of Out-of-State Licensure Status pdf 13k
doc 35k
 
NH-8 Application for Approval of Administrative Intern Program pdf 13k
doc 37k
 
NH-9 Quarterly Progress Report for Administrative Intern Program pdf 16k
doc 55k
 
NH-10 Certification of Program Completion for Nursing Home Administrative Intern Program pdf 13k
doc 41k
 

Surgical Practice Registration
Form # Title PDF/WORD Instruction/ Comments
HFEL-8 Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership pdf 35k
doc 125k
Instructions
pdf 20k
doc 31k  
Go to Division of Health Facilities Evaluation and Licensing     Additional Health Department Forms