| Form Number |
| AAS-5
|
Facility Inspection Worksheet
(Resident Rights, Physical Plant and Environment, Safety, Dietary Services) |
|
|
| AAS-11 |
Nurse Staffing Report
(Updated August 13, 2021) |
|
New fillable PDF form!
Word document no longer available.
|
|
| AAS-22
|
Adult Medical Day Care Inspection Information |
|
|
| AAS-23 |
Pediatric Medical Day Care Inspection Information |
|
|
| AAS-24
|
Affidavit of Compliance Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs |
|
|
| AAS-40 |
Affidavit of Compliance with N. J. Licensure Standards for Adult Day Health Care Facilities |
|
|
| AAS-45
|
Reportable Event Record/Report |
|
|
| AAS-55 |
Declaration of Compliance with Advisory Standards |
|
|
| AAS-59
|
Medical Day Inspection Information |
|
|
| AAS-60 |
Consumer Resident/Patient Complaint Report |
|
|
| AAS-61
|
Medical Day Care Assessment and Survey
Exit Conference Guide |
|
|
| AAS-80 |
Assisted Living Assessment and Survey
Exit Conference Guide |
|
|
| AAS-81
|
Assisted Living Entrance Guide |
|
|
| AAS-84 |
Affidavit of Compliance with N. J. Licensure Standards for Pediatric Medical Day Care Facilities |
|
|
| ACH
|
NJ Acute Care Hospitals Cost Reports |
|
|
NEW! fillable PDF form posted, Word document no longer available.
|
|
| ACS-16 |
Take Control of Your Health
Workshop Information Cover Sheet |
|
|
| ACS-17
|
Take Control of Your Health
Notification of Upcoming Workshop |
|
|
| ACS-18 |
Take Control of Your Health
Attendance Log |
|
|
| ACS-19
|
Take Control of Your Health
Participant Information Survey |
|
|
| ACS-19A |
Take Control of Your Health
Participant Information Survey (Spanish) |
|
|
| ACS-20
|
Take Control of Your Health
Workshop Evaluation |
|
|
| ACS-20A |
Take Control of Your Health
Workshop Evaluation (Spanish) |
|
|
| ACS-21
|
Take Control of Your Health
Participant Certificate of Completion Template |
|
|
| ACS-21A |
Take Control of Your Health
Participant Certificate of Completion Template (Spanish) |
|
|
| ACS-22
|
Take Control of Your Health
Peer Leader Agreement |
|
|
| ACS-23 |
Take Control of Your Health
Peer Leader Contact Information and Training Verification |
|
|
| ACS-24
|
Take Control of Your Health
Notification of Upcoming Peer Leader Training |
|
|
| ACS-27 |
Take Control of Your Health
Peer Leader Training Certificate of Completion |
|
|
| ACS-28
|
Take Control of Your Health
Master Trainer Checklist for Observing Peer Leaders |
|
|
| ACS-29 |
Take Control of Your Health
Group Leader Script (English) |
|
|
| ACS-29A
|
Take Control of Your Health
Group Leader Script (Spanish) |
|
|
| ACS-32 |
Take Control of Your Health
Workshop Checklist Summary |
|
|
| ACS-33
|
Take Control of Your Health
Non-Disclosure Agreement |
|
|
| APC-4 |
Veterinarian Co-Payment Fee Submission |
|
|
| APC-5
|
Application and Consent for Sterilization of Pets |
|
|
| APC-6 |
Animal Population Control Program
Veterinarian's Agreement (Updated April 23, 2018) |
|
|
NEW! fillable PDF form posted, Word document no longer available.
|
|
| APC-7
|
Payment Voucher / Veterinarian Reimbursement |
|
|
| APC-11 |
Animal Population Control Program Proxy Authorization |
|
|
| APC-12
|
Shelter/Pound Annual Report |
|
|
| ARR |
Rehabilitative Hospital and Special Hospital subject to a $10 Adjusted Admission Assessment |
|
|
| ASB-3
|
Asbestos Management Plan
Inspection Cover Sheet (Form A) |
|
|
| ASB-4 |
Asbestos Management Plan
Room/Functional Space Inspection (Form B) |
|
|
| ASB-5
|
Asbestos Management Plan
Cover Sheet (Form C) |
|
|
| ASB-6 |
Asbestos Management Plan, Room/Functional Space Inspection
Response Actions (Form D) |
|
|
| ASB-7
|
Asbestos Management Plan
Room/Functional Space
Boiler Room Response Actions (Form E) |
|
|
| ASB-8 |
Asbestos Management Plan
Homogeneous Material Identification (Form F) |
|
|
| ASB-9
|
Asbestos Management Plan
Listing of Laboratories Utilized for Sample Analysis (Form G) |
|
|
| ASB-10 |
Asbestos Management Plan
Summary of Laboratory Samples (Form H) |
|
|
| ASB-11
|
Asbestos Management Plan
Continuation Sheet (Form I) |
|
|
| ASB-12 |
Asbestos Management Plan
Description of Chain of Command (Form J) |
|
|
| ASB-13
|
Asbestos Management Plan
Plan for Reinspection (Form K) |
|
|
| ASB-14 |
Asbestos Management Plan
Plan for Operations and Maintenance Activities (Form L) |
|
|
| ASB-15
|
Asbestos Management Plan
Plan to Inform (Form M) |
|
|
| ASB-16 |
Asbestos Management Plan
Evaluation of Resources (Form N) |
|
|
| ASB-17
|
Asbestos Management Plan
Previous/Current Asbestos Abatement Log
(Form O) |
|
|
| ASB-18 |
Asbestos Management Plan
Major/Minor Fiber Release Episode Log (Form P) |
|
|
| ASB-19
|
Asbestos Management Plan
Statement of Ensurances (Form Q) |
|
|
| ASB-26 |
Facility Inspection Worksheet - Asbestos |
|
|
| ASB-41
|
Notification of Asbestos Abatement |
|
|
| BACT-44 |
Bacteriological Sample Submittal
(Updated November 28, 2016) |
|
|
| BACT-109
|
Request for Bacterial or Viral Culture or Parasite Identification |
|
|
| BIR-1 |
Commission on Brain Injury Research
Qualified Research Institution
Request for Approval
(Updated August 2020) |
|
|
| CB-2
|
Fatal/Serious Accident Report (Updated Jan 17) |
|
|
| CB-11 |
Application For Certificate of Approval To Operate a Youth Camp
(Updated April 5th, 2022) |
|
|
| CB-11A
|
Application For Certificate of Approval To Operate a Youth Camp
(Updated April 5th, 2022) |
|
|
| CB-14 |
Application For Certificate of Approval To Operate a Single Sport Youth Camp
(Updated April 5th, 2022) |
|
|
| CB-14A
|
Application For Certificate of Approval To Operate a Single Sport Youth Camp
(Updated April 5th, 2022) |
|
|
| CB-15 |
Annual Accident Report Youth Camp Safety Act |
|
|
| CB-17
|
Youth Camp Self-Inspection Report (for Youth Camp Operators) |
|
|
| CB-18 |
Youth Camp Safety Detailed Data Sheet (for Local Health Inspectors) |
|
|
| CB-19
|
Youth Camp Safety Detailed Data Sheet (for Youth Camp Operators) |
|
|
| CB-20 |
Certification for the Replacement of Main Drain Covers in Pool/Spa |
|
|
| CCR-27
|
Donation Mail-In Record |
|
|
| CDC-2 |
Report of Rabies Postexposure Treatment |
|
|
| CDC 50.42A
|
Adult HIV Confidential Case Report Form
(Updated 11/2019) |
|
|
| CDC 50.42B |
Pediatric HIV Confidential Case Report Form
(Updated 11/2019) |
|
|
| CDC 50.42D
|
Perinatal HIV Exposure Reporting (PHER) |
|
|
| 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-54.7
|
Trichinosis Surveillance Case Report |
|
|
| CDC-CNHGQ |
Cyclosporiasis Case Report
(Updated May 2nd, 2022) |
|
|
| CDC-LCR
|
Listeria Case Report
(Updated September, 2016) |
|
|
| CDC-MIS |
Multisystem Inflammatory Syndrome Associated with COVID-19: Case Report Form |
|
|
| CDS-1
|
For Reporting Reportable Communicable Diseases |
|
|
| CDS-6 |
Amoebiasis Report |
|
|
This form has been removed.
|
|
| CDS-7
|
Babesiosis Report |
|
|
| CDS-8 |
Creutzfeldt-Jacob Disease Report |
|
|
| CDS-9
|
Guillain-Barre Syndrome Report |
|
|
| CDS-10 |
Kawasaki Syndrome Disease Report |
|
|
| CDS-11
|
Patient Symptoms Line Listing (Respiratory Tract Infection) |
|
|
| CDS-12 |
Patient Symptoms Line Listing (Gastrointestinal Infection) |
|
|
| CDS-13
|
Food-Specific Attack Rate Worksheet |
|
|
| CDS-14 |
Lyme Disease Case Investigation
(Updated August 17, 2017) |
|
|
Use PDF (NEW!) for electronic AND hand-written completion. Word version contains instructions.
|
|
| CDS-15
|
Hemolytic Uremic Syndrome (Postdiarrheal) Report |
|
|
| CDS-16 |
Epidemiology Surveillance Record (Hospital-Based Laboratory) |
|
|
| CDS-17
|
Hepatitis C Report
(Updated 06-17-2021) |
|
|
| CDS-17A |
Hepatitis C Investigation Letter (short) |
|
|
| CDS-18
|
Report of Known or Suspected Avian Chlamydiosis (Psittacosis) |
|
|
| CDS-25 |
Avian Influenza Screening Information |
|
|
| CDS-26
|
Speakers' Bureau Request |
|
|
| CDS-30 |
Outbreak Report for Long Term Care and Other Institutions |
|
|
| CDS-31
|
Out-of-State Animal Bite Report |
|
|
| CDS-32 |
Zoonotic Disease Incident Report |
|
|
| CDS-33
|
Student Symptoms Line Listing |
|
|
| CDS-34 |
Scabies Case Line List: Residents |
|
|
| CDS-35
|
Scabies Case Line List: Staff |
|
|
| CDS-36 |
Investigation/Outbreak Intake Record |
|
|
| CDS-37
|
Hepatitis B Case Report |
|
|
| CDS-38 |
Outbreak Report for Child Care, School and Camp Settings |
|
|
| CDS-40
|
STEC Surveillance Case Report |
|
|
| CEHS-1 |
Child Care Center - Indoor Environmental Health Assessment Form A: Submission Information
(Updated MAR 2018)Submit Online (IEHA initial submission Forms cehs-1 to cehs-8) |
|
|
| CEHS-2
|
Child Care Center - Indoor Environmental Health Assessment Form B: Historical and Current Uses of Building and Site |
|
|
| CEHS-3 |
Child Care Center - Indoor Environmental Health Assessment Form C: Descriptions and Conditions of Building Components |
|
|
| CEHS-4
|
Child Care Center - Indoor Environmental Health Assessment Form D: Description of Heating and Cooling Systems |
|
|
| CEHS-5 |
Child Care Center - Indoor Environmental Health Assessment Form E: Water and Sewer Information |
|
|
| CEHS-6
|
Child Care Center - Indoor Environmental Health Assessment Form F: Hazardous Substances and Vapor Intrusion |
|
|
| CEHS-7 |
Child Care Center - Indoor Environmental Health Assessment Form G: Summary of Testing and Evaluation Results |
|
|
| CEHS-8
|
Child Care Center - Indoor Environmental Health Assessment Form H: Assessment Summary, Conclusions, Recommendations and Corrective Actions |
|
|
| CEHS-9 |
Indoor Environmental Consultant License Application |
|
|
| CEHS-10
|
Employee Qualifications: Lead Inspectors/Risk Assessor and Evaluation Contractor Information |
|
|
| CEHS-11 |
Employee Qualifications: Asbestos Inspectors |
|
|
| CEHS-12
|
Employee Qualifications: General Indoor Environmental Health Assessor |
|
|
| CEHS-13 |
Consultant/Employee Certification |
|
|
| CEHS-14
|
Employee Qualifications: Radon Certification Information |
|
|
| CEHS-15 |
Child Care Center - DOH Subsequent Notification
(Updated April 2018)Submit Online (preferred method) |
|
|
| CEHS-16
|
Indoor Environmental Consultant License Renewal Application |
|
|
| CEHS-17 |
Statement of Education and Experience Requirements
Lead Inspector / Risk Assessor |
|
|
| CEHS-18
|
Statement of Education and Experience Requirements
Supervisor for Housing and Public Buildings |
|
|
| CEHS-19 |
Statement of Education and Experience Requirements
Supervisor for Commercial Buildings and Superstructures |
|
|
| CEOH-1
|
Checklist for Public Recreational Bathing Facilities (Updated Jan 17) |
|
|
| CEOH-2 |
Notification of Non-Friable Asbestos Work Activities |
|
|
| CEOH-3
|
Notification of Non-Friable Asbestos Work Activities Related to Superstorm Sandy |
|
|
| CEOH-4 |
Contractor Information for Non-Friable Asbestos Work Activities
Exemption Request |
|
|
| CES-4
|
Request for Level A - Aggregate Data |
|
|
| CES-12 |
Hematology/Oncology Physician Report |
|
|
| CES-14
|
Radiation Therapy Facility Report Form |
|
|
| CES-15 |
Ambulatory Surgery Center Report Form |
|
|
| CES-17
|
Dentist Report Form |
|
|
| CES-18 |
Laboratory Report Form |
|
|
| CES-40
|
Physician Report Form (Non-Hospital Source) |
|
|
| CFO-1 |
Application for Cottage Food Operator Permit
(Updated October 6, 2021) |
|
|
| CH-2
|
Child Health Record |
|
|
| CH-2A |
Child Health Conference - Health Assessment (Infancy: 2-6 Weeks) |
|
|
| CH-2B
|
Child Health Conference - Health Assessment (Infancy: 2 Months) |
|
|
| CH-2C |
Child Health Conference - Health Assessment (Infancy: 4 Months) |
|
|
| CH-2D
|
Child Health Conference - Health Assessment (Infancy: 6 Months) |
|
|
| CH-2E |
Child Health Conference - Health Assessment (Infancy: 9 Months) |
|
|
| CH-2F
|
Child Health Conference - Health Assessment (Infancy: 12 Months) |
|
|
| CH-2G |
Child Health Conference - Health Assessment (Childhood: 15 Months) |
|
|
| CH-2H
|
Child Health Conference - Health Assessment (Childhood: 18 Months) |
|
|
| CH-2I |
Child Health Conference - Health Assessment (Childhood: 2 Years) |
|
|
| CH-2J
|
Child Health Conference - Health Assessment (Childhood: 3 Years) |
|
|
| CH-2K |
Child Health Conference - Health Assessment (Childhood: 4 Years) |
|
|
| CH-2L
|
Child Health Conference - Health Assessment (Childhood: 5 Years) |
|
|
| CH-2M |
Child Health Conference - Health Assessment (Childhood: 6 Years) |
|
|
| CH-2N
|
Child Health Conference - Health Assessment (Childhood: 7 Years) |
|
|
| CH-2O |
Child Health Conference - Health Assessment (Childhood: 8 Years) |
|
|
| CH-2P
|
Child Health Conference - Health Assessment (Childhood: 9 Years) |
|
|
| CH-2Q |
Child Health Conference - Health Assessment (Childhood: 10-12 Yrs) |
|
|
| CH-2R
|
Child Health Conference - Health Assessment (Childhood: 13-15 Yrs) |
|
|
| CH-2S |
Child Health Conference - Health Assessment (Childhood: 16-20 Yrs) |
|
|
| CH-5
|
Child Health Conference Encounter Record |
|
|
| CH-7 |
Child Health Services Quarterly Summary Report |
|
|
| CH-8
|
Patient Referral |
|
|
| CH-14 |
Universal Child Health Record
(Contact Child & Adolescent Health Program at 609-292-5666 for more information.)
(Updated October 6, 2017) |
|
|
| CH-15
|
Care Plan for Children with Special Health Needs |
|
|
| CH-16 |
Hearing Screening Report |
|
|
| CHEM-44
|
Organic and Inorganic Chemistry Sample Submittal |
|
|
| CL-3 |
Application for a Clinical Laboratory License
(Onsite Testing Only)
(Updated October 10, 2017) |
|
|
| CL-8
|
Blood Bank Annual Statistics (Out of Hospital and Emergency Only Transfusion Facilities) |
|
|
| CL-8A |
Blood Bank Annual Statistics (Hospitals) |
|
|
| CL-9
|
Disclosure of Ownership and Control Interest
(Updated October, 2016) |
|
|
| CL-13 |
Blood Bank Annual Statistics
(Hematopoietic Progenitor Cell Facilities) |
|
|
| CL-14
|
Blood Bank Annual Statistics
(Perioperative Autologous Blood Collection and Administration Facilities) |
|
|
| CL-16 |
Application for a Blood Bank License |
|
|
| CL-17
|
Blood Bank Annual Statistics (Umbilical Cord Blood Facilities) |
|
|
| CL-18 |
Application for a Clinical Laboratory License
(Collection Station Only) |
|
|
| CL-21
|
Error/Accident Report |
|
|
| CL-34 |
Laboratory Personnel Qualification Appraisal |
|
|
| CL-40
|
Blood Bank Personnel Qualification Appraisal |
|
|
| CL-44 |
Transfusion Reaction Report |
|
|
| CL-50
|
Brokers and Reagent Manufactureres - Annual Statistical Data |
|
|
| CL-51 |
Blood Centers - Annual Statistical Data |
|
|
| CL-58
|
Blood Bank License Fee |
|
|
| CMP-1 |
Request for Funding from Civil Monetary Penalties |
|
|
| CMS-116
|
Clinical Laboratory Improvement Amendments (CLIA) Application for Certification |
|
|
| CN-1 |
Full Review Certificate of Need Application for Long Term Care Facilities: General Long Term Care Beds; Specialized Long Term Care Beds
(Updated December 1, 2016) |
|
|
| CN-3
|
Application for Certificate of Need for Hospital-Related Projects
(Updated December 1, 2016) |
|
|
| CN-4 |
Application for Certificate of Need for Designation as a Perinatal Facility
(Updated December 1, 2016) |
|
|
| CN-6
|
Project Application for an Adult Day Health Services Facility
(Formerly HFEL-3)
(Updated May, 2016) |
|
|
| CN-7 |
Application for New or Amended Acute Care Facility License
(Last Updated November 10th, 2021) |
|
New fillable PDF form!
Word document no longer available.
|
|
| CN-8
|
Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility
(Formerly HFEL-4)
(Updated May, 2016) |
|
|
| CN-9 |
Health Care Facility Inquiry Regarding Health Care Professional (HFEL-9) (updated August 10,2017) |
|
|
| CN-10
|
Annual Report of Megavoltage Radiation Unit |
|
|
| CN-11 |
Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership (Formerly HFEL-8)
(Updated May, 2016) |
|
|
| CN-19
|
Certificate of Need Application-Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a)
(Updated December 1, 2016) |
|
|
| CN-28 |
Application for Waiver
(Updated November 3rd, 2021) |
|
New fillable PDF form!
Word document no longer available.
|
|
| CT-11
|
Records Release Authorization |
|
|
| CT-11A |
Records Release Authorization (spanish) |
|
|
| CT-14
|
HIV Consent Form (Serology) |
|
|
| CT-24 |
HIV Confidential Consent Form (Serology) |
|
|
| CT-24A
|
HIV Confidential Consent Form (Serology) (spanish) |
|
|
| CT-28 |
HIV Consent (Rapid Testing) - Confidential and Anonymous Testing |
|
|
| CT-28A
|
HIV Consent (Rapid Testing) (Confidential and Anonymous) (spanish) |
|
|
| CT-28B |
HIV Consent (Rapid Testing) (Confidential and Anonymous) (Creole) |
|
|
| CT-29
|
HIV Consent (Rapid Testing) - Confidential Testing Only |
|
|
| CT-29A |
HIV Consent (Rapid Testing) (Confidential Only) (spanish) |
|
|
| CT-29B
|
HIV Consent (Rapid Testing) (Confidential Only) (Creole) |
|
|
| DHAS-1 |
Grant Application Checklist |
|
|
| DHAS-2
|
Fringe Benefit Breakdown |
|
|
| DHAS-8 |
Application for Eligibility for the HIV Home Care Program |
|
|
| DHAS-9
|
Client Intake Record |
|
|
| DHAS-10 |
Physician Certification and Plan of Care |
|
|
| DHAS-20
|
Monthly Activity Report |
|
|
| DHAS-27 |
Application for Participation in the
AIDS Drug Distribution Program (ADDP) and/or the
Health Insurance Continuation Program (HICP) |
|
|
| DHAS-34
|
Renewal Application for Participation in the Health Insurance Continuation Program |
|
|
| DHAS-35 |
Title II Reports |
|
|
| DHAS-37
|
Certification by Physician (ADDP/HICP) |
|
|
| DHAS-38 |
Certification by Pharmacist |
|
|
| DHAS-39
|
Health Insurance Information
Health Insurance Continuation Program (HICP) |
|
|
| DHAS-40 |
Certification of Separation
AIDS Drug Distribution Program and
Health Insurance Continuation Program |
|
|
| DHAS-43
|
Confidential Laboratory Report |
|
|
| DHAS-44 |
Adult HIV/AIDS Confidential Case Report
(See CDC 50.42A) |
|
|
| DHAS-45
|
Pediatric HIV/AIDS Confidential Case Report
(See CDC 50.42B) |
|
|
| DPF-663 |
State of New Jersey
Application for Employment
(Updated 09/11/2020) |
|
|
| EHS-1
|
Application for Reciprocal Lead Permit |
|
|
| EHS-2 |
Renewal Application for Lead Training Agency Certification |
|
|
| EHS-4
|
Initial Application for Asbestos Training Agency Certification |
|
|
| EHS-5 |
Renewal Application for Asbestos Training Agency Certification |
|
|
| EHS-6
|
Application for Reciprocal Asbestos Accreditation
(Updated April 26th, 2022) |
|
|
| EHS-10 |
Facility Inspection Worksheet - Lead |
|
|
| EHS-15
|
Application for Approval as a NJ Asbestos Course Instructor |
|
|
| EHS-16 |
Application for Approval as a NJ Lead Course Instructor/Training Manager |
|
|
| EHS-21
|
Lead Training Course Notification |
|
|
| EHS-22 |
Application for Lead Permit Worker-Housing and Public Buildings |
|
|
| EHS-23
|
Application for Lead Permit Supervisor, Housing and Public Buildings |
|
|
| EHS-24 |
Application for Lead Permit Inspector/Risk Assessor |
|
|
| EHS-25
|
Application for Lead Permit Planner/Project Designer |
|
|
| EHS-26 |
Application for Lead Permit Worker, Commercial Buildings and Superstructures |
|
|
| EHS-27
|
Application for Lead Permit Supervisor, Commercial Buildings and Superstructures |
|
|
| EHS-28 |
Initial Application for Lead Training Agency Certification |
|
|
| EHS-29
|
Application for Replacement of Lead Permit |
|
|
| EHS-34 |
Application for Approval to Operate a Body Art Establishment (Permanent) For use by Local Health Department Officials only. |
|
|
| EHS-35
|
Application for Approval to Operate a Body Art Establishment (Temporary) For use by Local Health Department Officials only. |
|
|
| EHS-36 |
Body Art Infection/Injury Report For use by Local Health Department Officials only. |
|
|
| EHS-37
|
Asbestos Training Course Notification |
|
|
| EHS-38 |
Lead Training Course Proposal Checklist |
|
|
| EHS-39
|
Asbestos Training Course Proposal Checklist |
|
|
| EHS-40 |
Hands-on Assessment
Lead Worker - Housing and Public Buildings |
|
|
| EHS-41
|
Hands-On Assessment
Lead Worker-Commercial Buildings and Superstructures |
|
|
| EHS-42 |
Hands-On Assessment
Lead Inspector / Risk Assessor |
|
|
| EHS-43
|
Hands-On Assessment
Lead Supervisor - Housing and Public Buildings |
|
|
| EHS-44 |
Hands-On Assessment
Lead Supervisor - Commercial Buildings and Superstructures |
|
|
| EHS-45
|
Hands-On Assessment
Lead Planner / Project Designer |
|
|
| EHS-46 |
Request for Reciprocity
Verification of Lead Licensure Status with New York State
(Updated October, 2016) |
|
|
| EMS-10
|
EMT Verification Report |
|
|
| EMS-16 |
Survey Report for Mobility Assistance Vehicles (Sample) |
|
|
| EMS-19
|
Survey Report for Ambulance (Basic Life Support) (Sample) |
|
|
| EMS-20 |
Survey Report for Ambulance (Advanced Life Support) (Non-Transport) (Sample) |
|
|
| EMS-21
|
Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample) |
|
|
| EMS-24 |
Quarterly Report of Mobile Intensive Care Program |
|
|
| EMS-25
|
Quarterly Report of Specialty Care Transport Units |
|
|
| EMS-26 |
Quarterly Report for Basic Life Support Ambulances Providing Emergency Response |
|
|
| EMS-27
|
Quarterly Report for Air Medical Units |
|
|
| EMS-28 |
Emergency Medical Technician
Continuing Education Documentation
(With NJ/PA Logos) |
|
|
| EMS-28A
|
Emergency Medical Technician
Continuing Education Documentation
(without Logos) |
|
|
| EMS-38 |
Staff Roster |
|
|
| EMS-43
|
EMT Course Schedule |
|
|
| EMS-44 |
Application for Accreditation - Emergency Medical Technician Education Program |
|
|
| EMS-56
|
Application for Certification as an Emergency Medical Technician-Basic Instructor |
|
|
| EMS-57 |
Basic Life Support (BLS) Application for Provider Recertification |
|
|
| EMS-60
|
Advanced Life Support Application for Provider Recertification |
|
|
| EMS-61 |
Emergency Medical Technician Training Fund Final Reimbursement Report |
|
|
| EMS-62
|
Emergency Medical Technician (EMT) Training Fund Certificate of Eligibility for EMT Education |
|
|
| EMS-63 |
Form A / EMS First Responder
NJ Protocol for Scene Investigations of Infant and Child Deaths |
|
|
| EMS-64
|
EMT & Paramedic Clinician Reciprocity Application Verification of EMT & Paramedic Education and Licensure |
|
|
| EMS-65 |
EMT Training Fund Payment Voucher |
|
|
| EP-5
|
New Jersey Medical Reserve Corps User Enrollment Request |
|
|
| F-2 |
Registration of Drug or Medical Device Manufacturing or Wholesale Drug or Medical Device Business
(Updated May 23, 2022) |
|
|
| F-5
|
Bulk and Bottled Water Establishment Application
(Updated June 29th, 2022) |
|
|
| F-8 |
Initial Application for License to Operate a Refrigerated Warehouse and/or Locker Plant |
|
|
| F-9
|
Initial Application for License to Operate a Non-Alcoholic Beverage Manufacturing Plant |
|
|
| F-12 |
Application for Certificate of Free Sale (CFS) |
|
|
| F-13
|
Renewal or Discontinuation Application to Operate a Wholesale Drug or Medical Device Business
(Updated September 29, 2021) |
|
|
| F-17 |
Application for Permit to Handle Nitrous Oxide
(Updated June 23rd, 2022) |
|
|
| F-19
|
Renewal Application to Operate a Refrigerated Warehouse-Locker Plant
(Updated April 26th, 2022) |
|
|
| F-26 |
Self-Inspection Checklist (Wholesale) |
|
|
| F-27
|
Self-Inspection Checklist (Retail) |
|
|
| F-29 |
Initial Application for License to Operate a Wholesale Food-Cosmetic Establishment |
|
|
| F-30
|
Satisfactory Placard |
|
|
| F-31 |
Unsatisfactory Placard |
|
|
| F-32
|
Conditionally Satisfactory Placard |
|
|
| F-33 |
Sanitary Inspection Report |
|
|
| F-35
|
Retail Food Inspection Report (Local Health Departments) |
|
|
| F-37 |
Risk-Based Inspection Report (Local Health Departments) |
|
|
| F-39
|
Renewal Application to Operate a Non-Alcoholic Beverage and/or Bottling Plant
(Updated April 26th, 2022) |
|
|
| F-41 |
Renewal Application to Operate a Wholesale Food/Cosmetic Establishment
(Updated August 13, 2021) |
|
New fillable PDF form!
Word document no longer available.
|
|
| F-42
|
Renewal Application for Certification to Sell Bottled Water or Bulk Water
(Replaced by revised F-5 form on June 16th, 2022) |
|
|
| F-48 |
Application for Certification to Handle Oysters, Clams or Mussels |
|
|
| FHS-16
|
Initial Uniform Application for Services to Individuals 21 and Under with Developmental Disabilities |
|
|
| FHS-18 |
Formal Dispute Resolution Request |
|
|
| FHS-18A
|
Formal Dispute Resolution Request (Spanish)
(Solicitud de Resolution de Reclamo Formal) |
|
|
| FHS-19 |
Withdrawal of Dispute Resolution Request (formerly titled "Withdrawal of Complaint") |
|
|
| FHS-19A
|
Withdrawal of Complaint (Spanish) |
|
|
| FHS-22 |
Request for Technical Assistance |
|
|
| F-L3
|
Certificate of Free Sale Package (English) (including F-L3 and F-12 Forms) |
|
|
| F-L4 |
Certificate of Free Sale Package (Spanish) (including F-L4 and F-12 Forms) |
|
|
| FM-7
|
EMPLOYEE IDENTIFICATION (BUILDING/PARKING) MULTIFORM |
|
|
| FS-5 |
Report of Expenditures and Request for Reimbursement for Construction Grants |
|
|
| FS-20A
|
Report of Grant Expenditures |
|
|
| FS-27 |
Notification of Licensed Public Accountant |
|
|
| FS-40A
|
Personnel Costs and Justification |
|
|
| FS-40B |
Consultant Services Costs and Justification |
|
|
| FS-40C
|
Other Cost Categories and Justification |
|
|
| FS-45 |
Grant Progress Report |
|
|
| FS-57
|
Budget Revision Request |
|
|
| FS-63 |
Statement of Program Income |
|
|
| FS-77
|
Application for Mini-Grant Funds |
|
|
| FS-91 |
Statement of Interest Earned from Advance Payments Deposited into an Interest Bearing Account |
|
|
| FS-D4
|
Instructions for Completion of "Application for Mini-Grant Funds" (FS-77) |
|
|
| GRANTS |
Grant Application Package - General |
|
|
| GRANTS
|
Grant Application Package - Construction Grant (FS-26) |
|
|
| GRANTS |
Grant Application Package - Letter of Agreement |
|
|
| GRANTS
|
Grant Application Package - Multi-Year 2nd and 3rd Year (FS-20) |
|
|
| 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) |
|
|
| 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) |
|
|
| HCQ-3 |
Daily Patient Care Staffing: Inpatient Units |
|
|
| HCQ-3A
|
Daily Patient Care Staffing - Inpatient (Spanish) |
|
|
| HCQ-4 |
Daily Patient Care Staffing: Emergency Department |
|
|
| HCQ-4A
|
Daily Patient Care Staffing - Emergency Department (Spanish) |
|
|
| HCQ-5 |
Daily Patient Care Staffing: Post-Anesthesia Care Unit |
|
|
| HCQ-5A
|
Daily Patient Care Staffing - Post Anesthesia Care Unit (PACU) (Spanish) |
|
|
| HCQ-6 |
Daily Patient Care Staffing-Other Licensed Health Care Professionals: Hospital-Wide |
|
|
| HCQ-6A
|
Daily Patient Care Staffing - Other Licensed Health Care Professionals, Hospital Wide (Spanish) |
|
|
| HCQ-7 |
Cardiac Cathereterization Data Registry |
|
|
| HCQ-8
|
NJ Acute Stroke Registry
(Updated May 7, 2020) |
|
|
| HCQ-9 |
Open Heart Surgery Risk Stratification Project - Data Collection Form, Version 4.3
(Updated December, 2016) |
|
|
| HCQO-16
|
Non-Confidential Release |
|
|
| HFEL-3 |
Project Application for an Adult Day Health Services Facility
(Changed to CN-6, May, 2016) |
|
|
| HFEL-4
|
Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility
(Changed to CN-8, May, 2016) |
|
|
| HFEL-5 |
Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment
(Last edited April 19, 2022)
Submit Online |
|
|
| HFEL-6
|
Resident Care Staffing Report |
|
|
| HFEL-7 |
New Jersey Universal Transfer Form |
|
|
| HFEL-8
|
Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership
(Changed to CN-11, May, 2016) |
|
|
| HIP-5 |
Laboratory PreScreening Worksheet |
|
|
| IEM-3
|
Specimens for Newborn Biochemical Screening |
|
|
| IEM-15 |
Order form for Initial Newborn Screening Request (IEM-1) Forms |
|
|
| IMM-3
|
Annual College Immunization Status Report
(Updated January 25, 2022) |
|
|
NEW! Interactive PDF. DOWNLOAD & SAVE this file on your computer, then open in Adobe Reader.
|
|
| IMM-5 |
Varicella Case Report |
|
|
| IMM-6
|
Vaccines for Children Program
Vaccine Usage Report
(Updated April, 2016) |
|
|
| IMM-7 |
Annual Immunization Status Report |
|
|
| IMM-8
|
Standard School/Child Care Center Immunization Record
(To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.) |
|
|
| IMM-9 |
Personal Immunization Record
(To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.) |
|
|
| IMM-10
|
Rubella Surveillance Worksheet |
|
|
| IMM-11 |
Measles Surveillance Worksheet |
|
|
| IMM-12
|
Retrospective Immunization Audit / Survey |
|
|
| IMM-13 |
Flu Vaccine Tracking Record |
|
|
| IMM-14
|
Immunization Audit Report Worksheet |
|
|
| IMM-15 |
Immunization Audit Report
(Updated October 20, 2017) |
|
|
| IMM-16
|
Provisional Admittance Student Tracking Record |
|
|
| IMM-18 |
Vaccines for Children (NJVFC) Program
New Provider Enrollment for Adult Site
(Updated July, 2016) |
|
|
| IMM-20
|
Confidential Perinatal Hepatitis-B Case and Contact Report |
|
|
| IMM-21 |
Mumps Surveillance Worksheet |
|
|
| IMM-22
|
Tetanus Surveillance Worksheet |
|
|
| IMM-23 |
Meningococcal Disease Case Report |
|
|
| IMM-24
|
Pertussis Investigation Record |
|
|
| IMM-25 |
Vaccines for Children (VFC) Program
New Provider Agreement for Adult Sites
(Updated March 22, 2017) |
|
|
| IMM-26
|
Vaccines for Children (NJVFC) Program
VFC New Provider Enrollment for Pediatric Site
(Updated July, 2016) |
|
|
| IMM-28 |
Vaccines for Children (VFC) Program
Patient Eligibility Screening Record
(Updated July, 2016) |
|
|
| IMM-28A
|
317 Program
Patient Eligibility Screening Record
(Updated July, 2016) |
|
|
| IMM-29 |
New Jersey Immunization Information System (NJIIS)
Request for Change of User Security Authorization/
Request for Password Reset |
|
|
| IMM-30
|
Vaccines for Children Program
Provider Disenrollment Request
(Updated April, 2016) |
|
|
| IMM-31 |
Insured for Sure User Enrollment |
|
|
| IMM-32
|
NJIIS Consent to Participate (English) |
|
|
| IMM-32A |
NJIIS Consent to Participate (Spanish) |
|
|
| IMM-34
|
Site Enrollment Request: Early Hearing Detection and Intervention Program |
|
|
| IMM-35 |
User Enrollment and Training Request: Early Hearing Detection and Intervention Program |
|
|
| IMM-36
|
Vaccines for Children (VFC) Program
New Provider Agreement for Pediatric Sites
(Updated March 22, 2017) |
|
|
| IMM-40 |
New Jersey Immunization Information System (NJIIS)
Duplicate Record |
|
|
| IMM-41
|
NJIIS User Enrollment and Training Request |
|
|
| IMM-42 |
Enrollment Request for New NJIIS Site |
|
|
| IMM-43
|
User Confidentiality Statement for Access to NJIIS/ User Confidentiality Agreement |
|
|
| IMM-45 |
Request for Change to NJIIS Immunization Record |
|
|
| IMM-46
|
Request for Copy of NJIIS Immunization Record |
|
|
| IMM-47 |
Registrant Withdrawal from NJIIS |
|
|
| IMM-48
|
Vaccines for Children Program
Request to Update Provider Information
(Updated April, 2016) |
|
|
| IMM-49 |
Yellow Fever Vaccine Program
Application for Certified Yellow Fever Uniform Stamp |
|
|
| IMM-50
|
Yellow Fever Vaccine Program
Acknowledgement of Program Requirements |
|
|
| IMM-51 |
Yellow Fever Vaccine Program
Designation of Additional Yellow Fever Vaccination Centers |
|
|
| IMM-52
|
Yellow Fever Vaccine Program
Change Notification |
|
|
| IMM-53 |
Request for Medical Exemption From Mandatory Immunization |
|
|
| IMM-PKG-A
|
Vaccines for Children (NJVFC) Program
New Provider Enrollment Package (Adult)
(Updated March 22, 2017) |
|
|
| IMM-PKG-P |
Vaccines for Children (NJVFC) Program
New Provider Enrollment Package (Pediatric)
(Updated March 22, 2017) |
|
|
| IRB-1
|
Application for Initial Review |
|
|
| IRB-2 |
Application to Continue Human Subjects Research |
|
|
| IRB-3
|
Application to Modify Human Subjects Research |
|
|
| LAB-3 |
Request for Microbiological Testing of Food Sample |
|
|
| LAB-5 CLINICAL
|
Request for Testing of Suspected Pathogens of Public Health Significance and Chain of Custody |
|
|
| LAB-7 |
HIV Test Requisition |
|
|
| LAB-10
|
Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT) |
|
|
| LCS-4 |
Communicable Disease Alert |
|
|
| LCS-5
|
Application for the Addition of Long-Term Care Beds
(Updated May, 2016) |
|
|
| LCS-8 |
Facility Reporting Incident Data and Analysis Yield (FRIDAY) |
|
|
| LCS-9
|
Application for a Long-Term Care Facility License
(Updated May 23, 2022) |
|
|
| LH-7 |
Application for Registered Environmental Health Specialist Examination |
|
|
| LH-8
|
Application for Health Officer Examination |
|
|
| LH-9 |
Uniform Shared Services Agreement (Template) for Local Public Health Services |
|
|
| LH-12
|
New Jersey Local Health Report
Account Creation and Access Request
(Updated June 2016) |
|
|
| LH-13 |
Red Book-Local Health Emergency Contact Directory
Account Creation and Access Request
(Updated June 2016) |
|
|
| LP-3
|
Report of Childhood Blood Lead Analysis by Independent Laboratory (for children 16 years of age and under) |
|
|
| 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 |
|
|
| M-3
|
Application for a Milk Plant or a Bulk Milk Hauler (BTU) Permit
(Updated June 16th, 2022) |
|
|
| M-5 |
License to Manufacture Frozen Desserts Establishment Application
(Updated June 16th, 2022) |
|
|
| M-6
|
Renewal Application to Operate a Frozen Dessert Plant
(Replaced by revised M-5 form on June 16th, 2022) |
|
|
| M-7 |
Application for Temporary Marketing Permit:
Frozen Desserts Manufacturing Plant |
|
|
| M-8
|
Renewal Application to Operate a Bulk Tank Unit/Milk Plant
(Replaced by revised M-3 form on June 16th, 2022) |
|
|
| MAID-2 |
Mental Health Professional Compliance Form
(Updated October 8th, 2021) |
|
|
| MAID-3
|
Attending Physician Follow Up Form
(Updated October 8th, 2021) |
|
|
| MAID-4 |
Medication Dispensing Record
(Updated October 15th, 2021) |
|
|
| MAID-5
|
Consulting Physician Compliance Form
(Updated October 8th, 2021) |
|
|
| MAID-6 |
Request for Medication To End My Life in a Humane and Dignified Manner
(Updated October 8th, 2021) |
|
|
| MAID-7
|
Attending Physician Compliance Form
(Updated October 8th, 2021) |
|
|
| MH-A1 |
Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (MH) |
|
|
| MMH-1
|
Chronic Disease Self-Management Program
"Take Control of Your Health"
Pre-Workshop Participant Survey (English) |
|
|
| MMH-1A |
Chronic Disease Self-Management Program
"Take Control of Your Health"
Pre-Workshop Participant Survey (Spanish) |
|
|
| MMH-2
|
Chronic Disease Self-Management Program
"Take Control of Your Health"
Post-Workshop Participant Survey (English) |
|
|
| MMH-2A |
Chronic Disease Self-Management Program
"Take Control of Your Health"
Post-Workshop Participant Survey (Spanish) |
|
|
| MMH-3
|
Diabetes Self-Management Program
"Take Control of Your Health"
Pre-Workshop Participant Survey (English) |
|
|
| MMH-3A |
Diabetes Self-Management Program
"Take Control of Your Health"
Pre-Workshop Participant Survey (Spanish) |
|
|
| MMH-4
|
Diabetes Self-Management Program
"Take Control of Your Health"
Post-Workshop Participant Survey (English) |
|
|
| MMH-4A |
Diabetes Self-Management Program
"Take Control of Your Health"
Post-Workshop Participant Survey (Spanish) |
|
|
| MMH-5
|
Faithful Families Eating Smart and Moving More
Healthy Food Policy |
|
|
| MMH-6 |
Faithful Families Eating Smart and Moving More
Physical Activity Policy |
|
|
| MMH-7
|
Faithful Families Eating Smart and Moving More
Participant Entry Survey (English) |
|
|
| MMH-8 |
Faithful Families Eating Smart and Moving More
Participant Exit Survey (English) |
|
|
| MMH-9
|
Faithful Families Eating Smart and Moving More
Class or Program Evaluation (English) |
|
|
| MMP-1 |
Law Enforcement Incident Report |
|
|
| MS-5
|
Continuation Sheet |
|
|
| 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 |
|
|
| NA-11
|
Addendum: CMA Training - List of Course Attendees |
|
|
| NH-1 |
Application for Nursing Home Administrator License
(Updated September 1, 2021) |
|
|
| NH-5
|
Sponsor Application for Continuing Education Program Approval for Licensed Nursing Home Administrators
(Updated January, 2017) |
|
|
| NH-6 |
Request for Reciprocity
Verification of Out-of-State Licensure Status
(Updated September, 1, 2021) |
|
|
| NH-8
|
Application for Approval of Administrative Intern Program
(Updated September 1, 2021) |
|
|
| NH-9 |
Quarterly Progress Report for
Nursing Home Administrative Intern Program
(Updated September 1, 2021) |
|
|
| NH-10
|
Certification of Program Completion for Nursing Home Administrative Intern Program
(Updated September 1, 2021) |
|
|
| OAS-F2 |
PDF Download Instructions |
|
|
| OC-8
|
Medicinal Marijuana Petition
(Form is not currently available for use.) |
|
|
| OC-18 |
Request for Meeting with Commissioner
(Updated February 21, 2017) |
|
|
| OC-19
|
Commissioner Event Attendance Request
(Updated September 16, 2021) |
|
|
| OC-34 |
Government Records Request (OPRA) |
|
|
| OC-37
|
Institutional Approval of Intramural Research |
|
|
| OC-40 |
IRB Submission Checklist |
|
|
| OC-41
|
Agreement for Ethical Conduct of Human Subjects Research |
|
|
| OC-45 |
Agreement for Ethical Conduct of Human Subjects Research (Federal Employees) |
|
|
| OC-51
|
Notice of Claim of Exemption of Tobacco Retail Establishment |
|
|
| OC-53 |
Application for Registration of Exempt Cigar Bar or Lounge |
|
|
| OC-54
|
Application for Renewal of Registration of Exempt Cigar Bar or Lounge |
|
|
| OC-56 |
NJ Smoke Free Air Act / Complaint
(Updated January 25,2022) |
|
|
| OC-58
|
NJ Smoke Free Air Act / Anonymous Request for Investigation
(Updated January 25,2022) |
|
|
| OC-59 |
Notice - Smoke Free Air Act
(Updated January 25,2022) |
|
|
| OCC-1
|
Sharps Injury Log |
|
|
| OCC-2 |
Exposure Incident Report |
|
|
| OCC-3
|
Request for Source Individual Evaluation |
|
|
| OCC-4 |
Employee Exposure Determination |
|
|
| OCC-5
|
Employee Exposure Follow up Record |
|
|
| OCC-6 |
Hepatitis B Vaccine Immunization Record |
|
|
| OCC-8
|
Hepatitis B Declination Statement |
|
|
| OCC-9 |
Employee Education and Training Record |
|
|
| OCC-12
|
Public Employees Occupational Safety and Health (PEOSH) Unit Request for On-Site Consultation |
|
|
| OCC-15 |
Cleaning Schedule |
|
|
| OCC-16
|
EMS Respiratory Protection Program Evaluation Questionnaire |
|
|
| OCC-22 |
Documentation of Respirator Training |
|
|
| OCC-23
|
PEOSH Respirator Medical Evaluation Questionnaire |
|
|
| OCC-24 |
Firefighter Respirator Medical Evaluation Questionnaire |
|
|
| OCC-25
|
Documentation of Medical Evaluation for Respirator Use |
|
|
| OCC-30 |
Firefighter Respirator Fit Test Record |
|
|
| OCC-31
|
Occupational and Environmental Disease, Injury, or Poisoning Report by Health Care Provider
(Updated December 14, 2016) |
|
|
| OCC-32 |
EMS Responder Fit Test Record |
|
|
| OCC-33
|
Firefighter SCBA After Use/Daily Inspection Checklist |
|
|
| OCC-34 |
Clinical Laboratory Report of Elevated Levels of Heavy Metals:Lead: In Adults (Greater than 16 Years of Age)Arsenic, Cadmium, Mercury: In Persons of Any Age |
|
|
| OCC-37
|
PEOSH Hazard Communication Standard, Documentation of Training |
|
|
| OCC-38 |
PEOSH Hazard Communication Standard
Brief Self-Inspection Checklist |
|
|
| OCC-40
|
Worksheet for Hazardous Chemical List |
|
|
| OCC-41 |
Sample Letter for Requesting Safety Data Sheets (SDS's) |
|
|
| OCC-46
|
Worker and Community Right to Know Act / Employer Outreach Survey |
|
|
| OCC-54 |
Quarterly Report of RTK County Lead Agencies |
|
|
| OCC-57
|
Public Employees Occupational Safety and Health (PEOSH) Unit Complaint |
|
|
| OPSP-1 |
J-1 Visa Waiver / State Conrad 30 Program - Physician-Primary Care Survey, Initial/Biannual Service Report |
|
|
| OPSP-2
|
J-1 Visa Waiver / State Conrad 30 Program - Application for New Jersey |
|
|
| OPSP-2A |
Attachment A: Current Medical Staffing at Practice Site |
|
|
| OPSP-2B
|
Attachment B: Health Care Resources Inventory |
|
|
| OPSP-2C |
Attachment C: Facility Current Sliding Fee Scale |
|
|
| OPSP-2D
|
Attachment D: J-1 Physician Visa Waiver / State Conrad 30 Program - Statements |
|
|
| OPSP-3 |
Section 4-1, Health Facility's J-1 Visa Waiver / State Conrad 30 Program - Agreement |
|
|
| OPSP-4
|
Section 4-2, Physician J-1 Visa Waiver / State Conrad 30 Program - Affidavit and Agreement |
|
|
| OPSP-5 |
Section 5, J-1 Visa Waiver Required Application Enclosures |
|
|
| OTC-1
|
American Cancer Society (ACS) Monthly Activity Report |
|
|
| OTC-2 |
GASP Monthly Activity Report |
|
|
| OTC-3
|
Mom's Quit Connection (MQC) Monthly Activity Report |
|
|
| OTC-4 |
Regional Grantee Monthly Activity Report |
|
|
| PG-1
|
Requisition for Printing and Graphic Design
(Updated December 5, 2016) |
|
|
| PHSS-1 |
Application for Tanning Facilities Registration
(Updated August, 2016) |
|
|
| PHSS-3
|
Tanning Facility Inspection Checklist
(Updated August, 2016) |
|
|
| PHSS-4 |
Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects |
|
|
| PHSS-6
|
Confidential Medical Waste Exposure Report |
|
|
| PSP-1 |
Questionnaire to Assess Your Exposure Risk for Lead and Mercury (Quicksilver) |
|
|
| PV 6-93
|
Payment Voucher (Vendor Invoice)
(Updated May, 2016) |
|
|
| RAD-4 |
Radioanalytical Services Sample Submittal |
|
|
| REG-1
|
Quarterly Report of Domestic Partnerships Registered
(Updated April 2, 2018) |
|
|
| REG-2 |
Delegation of Authority to Receive Certified Copy of Vital Record (Birth/Death)
(Updated December 26, 2017) |
|
|
| REG-3
|
Delegation of Authority to Receive Certified Copy
(Marriage/Civil Union)
(Updated December 26, 2017) |
|
|
| REG-5 |
Report of No Births, Marriages, Civil Unions, Domestic Partnerships or Fetal Deaths
(Updated April, 2016) |
|
|
| REG-7E
|
Application for a Certified Copy of a "No Record of Marriage" Statement (English/Spanish)
(Updated November 23, 2016) |
|
|
| REG-13 |
Certified Municipal Registrar Recertification Course Tracking Log
(Updated January, 2015) |
|
|
| REG-14
|
Disinterment-Transit Permit |
|
|
| REG-15 |
Application to Amend a New Jersey Vital Record /
Application for a Certified Copy of Amended Record
(Updated February 7, 2019) |
|
|
| REG-20
|
Authorization for Release of Cause of Death
Autorización para la Emision de Causa de Muerte
(Combined English and español) |
|
|
| REG-23X |
Template for Electronic Remarriage License and Certificate
[Set up for Use on Traditional Laser Printers]
(New as of March 1, 2017) |
|
|
| REG-23X_MFP
|
Template for Electronic Remarriage License and Certificate
[Set up for Use on Multifunction Peripheral (MFP) Devices]
(New as of March 1, 2017) |
|
|
| REG-24X |
Template for Electronic Marriage License and Certificate
[Set up for Use on Traditional Laser Printers]
(Updated March 1, 2017) |
|
|
| REG-24X_MFP
|
Template for Electronic Marriage License and Certificate
[Set up for Use on Multifunction Peripheral (MFP) Devices]
(Updated March 1, 2017) |
|
|
| REG-25 |
Notification of Marriage/Civil Union
(Updated November 1, 2016) |
|
|
| REG-26
|
Certificate of Fetal Death
(Updated July 19, 2018) |
|
|
| REG-27A |
Application for a Non-Genealogical Certification or Certified Copy of a Vital Record
(English, fillable PDF with instructions)
(Updated April 30, 2019) |
|
|
| REG-27B
|
APLICACIÓN PARA COPIAS CERTIFICADAS Ó CERTIFICACIONES DE REGISTROS CIVILES NO-ANCESTRO
(fillable PDF, Español con Instrucciones)
(Updated October 5, 2017) |
|
|
| REG-28A |
Application for a Genealogical Certification or Certified Copy of a Vital Record
(fillable PDF, English, with instructions)
(Updated May 9, 2018) |
|
|
| REG-28B
|
APLICACIÓN POR UNA COPIA CERTIFICADA Ó CERTIFICACIONES DE UN REGISTRO CIVIL ANCESTRO
(fillable PDF, Español con Instrucciones)
(Updated May 9, 2018) |
|
|
| REG-33 |
Short Form Birth Certificate
(Replaces the REG-42D (1) and REG-42D (2))
(Updated February 7th, 2022) |
|
|
| REG-33b
|
Short Form Birth Certificate Version B
(Replaces the REG-42D (1) and REG-42D (2))
(Updated February 7th, 2022) |
|
|
| REG-34 |
Amendment to New Jersey Vital Record of
Birth, Death, Fetal Death, Marriage, Remarriage, Civil Union, Domestic Partnership
(Replaces REG-35, REG-45, REG-56 and REG-60 Forms)
(Updated March 3, 2017) |
|
|
| REG-35
|
Correcting a Birth Record for Child Whose Natural Parents Married After Its Birth
(Replaced by revised REG-34 form on August 1, 2016) |
|
|
| REG-36 |
New Records System for Birth Parents
Forms Package includes:
Form A, Contact Preference, and
Form B, Family History Information
(Updated January 1, 2017) |
|
|
| REG-36A
|
New Records System for Birth Parents
Form A, Contact Preference Form |
|
|
| REG-36B |
New Records System for Birth Parents
Form B, Family History Information Form |
|
|
| REG-37A
|
Application for Non-Genealogical Certification or Certified Copy of a Vital Record for Local Use
(fillable PDF, English, with instructions)
(Updated October 5, 2017) |
|
|
The forms are now ONLY available for download on the EDRS System.
|
|
| REG-37B |
APLICACIÓN PARA COPIAS CERTIFICADAS Ó CERTIFICACIONES DE REGISTROS CIVILES NO-ANCESTRO for Local Use
(fillable PDF, Español con Instrucciones)
(Updated October 5, 2017) |
|
|
The forms are now ONLY available for download on the EDRS System.
|
|
| REG-38A
|
Application for Genealogical Certification or Certified Copy of a Vital Record for Local Use
(fillable PDF, English, with instructions)
(Updated October 5, 2017) |
|
|
The forms are now ONLY available for download on the EDRS System.
|
|
| REG-38B |
APLICACIÓN POR UNA COPIA CERTIFICADA Ó CERTIFICACIONES DE UN REGISTRO CIVIL ANCESTRO
(fillable PDF, Español con Instrucciones)
(Updated October 5, 2017) |
|
|
The forms are now ONLY available for download on the EDRS System.
|
|
| REG-40
|
Attestation to Birth Certificate
(Updated November 21, 2016) |
|
|
| REG-41 |
Application for an Uncertified Copy of an Adopted Person's Original Birth Record |
|
|
| REG-42F(1)
|
Marriage Template (long form with Parents' Names)
for use on REG-42A Certified Copy Paper
(Updated November, 2013) |
|
|
| REG-42F(2) |
Marriage Template (short form without Parents' Names)
for use on REG-42A Certified Copy Paper
(Updated November, 2013) |
|
|
| REG-42G
|
Death Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014) |
|
|
| REG-42H |
Domestic Partnership Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014) |
|
|
| REG-42I (1)
|
Civil Union Template (without Parent Names)
for use on REG-42A Certified Copy Paper
(Updated April, 2014) |
|
|
| REG-42I(2) |
Civil Union Template (with Parent Names)
for use on REG-42A Certified Copy Paper
(Updated April, 2014) |
|
|
| REG-42J
|
Remarriage Template
for use on REG-42A Certified Copy Paper
(Updated October, 2013) |
|
|
| REG-42K |
Reaffirmation of Civil Union Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014) |
|
|
| REG-43
|
Transmittal of Court Order of Paternity
(Updated February 7, 2019) |
|
|
| REG-44 |
Report of Adoption
Registrar una Adopción
(Updated February 7, 2019) |
|
|
| REG-45
|
Request for Legal Name Change to Original Record of Birth, Marriage, Civil Union or Domestic Partnership
(Replaced by revised REG-34 form on August 1, 2016) |
|
|
| REG-56 |
Correcting a Birth Record for Out-of-Wedlock Child Whose Mother Married a Man Other Than the Natural Father
(Replaced by revised REG-34 form on August 1, 2016) |
|
|
| REG-60
|
Correcting the Birth Record of a Child Said to Have Been Born Out-of-Wedlock and Whose Natural Parents Have Not Married Each Other
(Replaced by revised REG-34 form on August 1, 2016) |
|
|
| REG-62 |
Request to Purchase Certified Copy of Vital Records Forms
(Updated January 14, 2022) |
|
|
| REG-64
|
Consent for Artificial Insemination
(Updated December, 2015) |
|
|
| REG-66 |
Log of Voided Certified Copy Forms |
|
|
| REG-68
|
Request to Place on File a Certificate of Birth Resulting in Stillbirth
(Solicitud para Archivar un Registro de Partida de Nacimiento Resultando en Parto Muerto) |
|
|
| REG-69 |
Quarterly Report of Non-EDRS Burial Permits Issued
(Updated April 2, 2018) |
|
|
| REG-77
|
Application for License: Marriage, Remarriage, Civil Union, or Reaffirmation of Civil Union
(Updated April 8, 2019) |
|
|
| REG-77A |
Application for License: Marriage, Remarriage, Civil Union or Reaffirmation of Civil Union (Combined English and Spanish)
(Solicitud Para Licencia: Matrimonio, Rematrimonio, Union Civil, o Reafirmacion de Union Civil)
(Updated April 4, 2019) |
|
|
| REG-D7
|
Notice of Rights and Obligations of Domestic Partners |
|
|
| REG-D7A |
Notice of Rights and Obligations of Domestic Partners (Spanish) |
|
|
| REG-D30
|
"Entering into a Marriage or Civil Union in New Jersey" Brochure
(Updated April 20th, 2022) |
|
|
| REG-D30A |
"Entering into a Marriage or Civil Union in New Jersey" Brochure (Spanish)
(Updated April 20th,2022) |
|
|
| REG-D30B
|
"Entering into a Marriage or Civil Union in New Jersey" Brochure (Russian)
(Updated April 20th, 2022) |
|
|
| REG-D30C |
"Entering into a Marriage or Civil Union in New Jersey" Brochure (Korean)
(Updated April 20th, 2022) |
|
|
| REG-D33
|
"Registering a Domestic Partnership in New Jersey" Brochure |
|
|
| REG-D33A |
"Registering a Domestic Partnership in New Jersey" Brochure (español) |
|
|
| REG-D33B
|
"Registering a Domestic Partnership in New Jersey" (Russian) |
|
|
| REG-D33C |
"Registering a Domestic Partnership in New Jersey" (Korean) |
|
|
| REG-D34
|
Guidelines for Requesting to Place on File a Certificate of Birth Resulting in Stillbirth (English/español)
(Updated November 21, 2016) |
|
|
| REG-L2 |
Request Form and Attestation to Amend Sex Designation on a Birth Certificate for an Adult to Reflect Gender Identity |
|
|
| REG-L3
|
Parent/Guardian Request Form and Attestation to Amend Sex Designation on a Birth Certificate for a Minor to Reflect Gender Identity |
|
|
| SCH-0 |
Special Child Health Services Registration Form |
|
|
| SCH-1
|
Autism Registration
(Updated November 16, 2016)
(This revised form is to be used in place of the SCH-0/SCH-1 combination.) |
|
|
| SCH-2 |
Newborn Hearing Follow-Up Report |
|
|
| SCH-3
|
Lost to Hearing Follow Up Report |
|
|
| SCH-6 |
Critical Congenital Heart Defects Screening Program
Aggregate Report |
|
|
| SCH-7
|
Notice of Availability of Supplemental Newborn Screening |
|
|
| SCH-7A |
Notice of Availability of Supplemental Newborn Screening (spanish) |
|
|
| SCH-13
|
Request for Hearing Aids |
|
|
| SCR |
Online Spinal Cord Research Grant Applications |
|
|
| SCR-1
|
Commission on Spinal Cord Research
Qualified Research Institution
Request for Approval
(Updated November, 2018) |
|
|
| SRD-1 |
Request for Viral Serology, Culture and Molecular Diagnostics |
|
|
Instructions included on page 2 of form.
|
|
| SRD-4
|
Request for Immunological/Isolation Services - Clinical Services Testing Unit |
|
|
| STD-11 |
Confidential Sexually Transmitted Disease Report
(Updated Dec, 2018) |
|
|
| STD-17
|
STD Program Medication Request |
|
|
| SUD-A1 |
Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (SUD) |
|
|
| SUD-A2
|
APPLICATION FOR NEW OR AMENDED RESIDENTIAL SUBSTANCE USE DISORDER TREATMENT FACILITY LICENSE N.J.A.C. 10:161A |
|
|
| TB-1 |
Quarterly Chest Clinic Activity Report |
|
|
| TB-3
|
Medication Request Order
(Updated March, 2016) |
|
|
| TB-4 |
TB Field Referral |
|
|
| TB-5
|
Symptom Assessment for Pulmonary Tuberculosis (TB) |
|
|
| TB-8 |
Religious Exemption - School TB Testing/Symptom Assessment Form |
|
|
| TB-9
|
Statement of Non-Infectiousness for Symptomatic Individual |
|
|
| TB-10 |
Statement of Non-Infectiousness for Individual with TB Disease |
|
|
| TB-41
|
Record of Contact Interview (Original + 1 Continuation Page) |
|
|
| TB-41 |
Record of Contact Interview (Original + 2 Continuation Pages) |
|
|
| TB-41
|
Record of Contact Interview (Original + 5 Continuation Pages) |
|
|
| TB-43 |
Tuberculosis (TB) Testing Survey Results |
|
|
| TB-57
|
Annual Report of TB Testing in Schools |
|
|
| TB-70 |
New Jersey Tuberculosis Case, Suspect and Status Report |
|
|
| VAERS
|
Vaccine Adverse Event Reporting System: Online |
|
|
| VIR-1 |
Requisition for Viral Serology |
|
|
Complete per instructions on form
|
|
| VIR-16
|
Request for Rabies Examination
(Updated April, 2016) |
|
|
| VPH-1 |
Inspection Report of Kennels, Pet Shops, Shelters, and Pounds |
|
|
| VPH-2
|
Animal Rescue Organization Registration |
|
|
| VPH-3 |
List of Licensed Kennels, Pet Shops, Shelters and Pounds |
|
|
| VPH-10
|
Monthly Dog License Report |
|
|
| VPH-11 |
Notice of Animal Bite and Confinement |
|
|
| VPH-20
|
Certification of Veterinary Supervision of the Disease Control and Health Care Program at a Licensed Animal Facility
(Updated May, 2016) |
|
|
| VPH-23 |
Notice of Intent, State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November 28, 2016) |
|
|
| VPH-25
|
State-Sponsored Municipal Rabies Vaccination Clinic Report
(Updated December 7th, 2021) |
|
|
| VPH-26 |
Rabies Vaccination Certificate |
|
|
| VPH-28
|
Certificate of Exemption from Rabies Vaccination |
|
|
| VPH-32 |
Application for Animal Control Officer Certification |
|
|
| VPH-35
|
Rabies Testing Notification Form |
|
|
| W-9 |
Vendor Questionnaire |
|
|
| WIC-6
|
WIC Vendor Selection Criteria
(Updated 11/8/2017) |
|
|
| WIC-8 |
New Jersey Division of Taxation
Authorization for Release of Tax Return Information |
|
|
| WIC-11
|
Medical Documentation for WIC Formula and Approved WIC Foods for Infants, Children and Women
(Updated April, 2016) |
|
|
| WIC-12 |
Designation of Infant Formula Manufacturer, Retailer, Wholesaler and Distributor |
|
|
| WIC-15A
|
Vendor Agreement (without signature page)
(October 1, 2015 - September 30, 2018) |
|
|
| WIC-21 |
Authorization AGreement for DirectDeposit (ACH) Credits |
|
|
| WIC-26
|
WIC Commodity Price List Survey
(Updated October 31, 2017) |
|
|
| WIC-32 |
WIC Services
FMNP-SFMNP/CSFP COMPLAINT REPORT |
|
|
| WIC-40
|
Application for WIC Vendor Authorization |
|
|
| WIC-41 |
NJ WIC Health Care Referral (Women)
(Updated April, 2016) |
|
|
| WIC-42
|
NJ WIC Health Care Referral (Infants and Children)
(Updated April, 2016) |
|
|
