The forms are listed alphabetically by form number in PDF and Word template format. feedback

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Form Number Form Name/Title Linked File Instructions
AAS-5 Facility Inspection Worksheet
(Resident Rights, Physical Plant and Environment, Safety, Dietary Services)
pdf (32k)
doc (95k)
 
 
AAS-11 Nurse Staffing Report
(Updated August 13, 2021)
pdf (284k)
 
New fillable PDF form!
Word document no longer available.
 
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 (74k)
 
 
AAS-40 Affidavit of Compliance with N. J. Licensure Standards for Adult Day Health Care Facilities
pdf (14k)
doc (42k)
 
 
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 (17k)
doc (57k)
 
 
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 (1322k)
 
 
AAS-81 Assisted Living Entrance Guide
pdf (781k)
 
 
AAS-84 Affidavit of Compliance with N. J. Licensure Standards for Pediatric Medical Day Care Facilities
pdf (13k)
doc (39k)
 
 
ACH NJ Acute Care Hospitals Cost Reports
ACH (295k)
 
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
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 (Updated April 23, 2018)
pdf (792k)
 
NEW! fillable PDF form posted, Word document no longer available.
 
APC-7 Payment Voucher / Veterinarian Reimbursement
pdf (28k)
doc (3063k)
 
 
APC-11 Animal Population Control Program Proxy Authorization
pdf (11k)
doc (33k)
 
 
APC-12 Shelter/Pound Annual Report
pdf (13k)
doc (91k)
 
Instructions (pdf 13k)
Instructions (doc 32k)
 
ARR Rehabilitative Hospital and Special Hospital subject to a $10 Adjusted Admission Assessment
pdf (755k)
 
Instructions (pdf 86k)
 
ASB-3 Asbestos Management Plan
Inspection Cover Sheet (Form A)
pdf (12k)
doc (42k)
 
Guide to Completing Asbestos Management Plan Forms (pdf 34k)
Guide to Completing Asbestos Management Plan Forms (doc 45k)
 
ASB-4 Asbestos Management Plan
Room/Functional Space Inspection (Form B)
pdf (12k)
doc (50k)
 
 
ASB-5 Asbestos Management Plan
Cover Sheet (Form C)
pdf (13k)
doc (53k)
 
 
ASB-6 Asbestos Management Plan, Room/Functional Space Inspection
Response Actions (Form D)
pdf (14k)
doc (65k)
 
 
ASB-7 Asbestos Management Plan
Room/Functional Space
Boiler Room Response Actions (Form E)
pdf (14k)
doc (68k)
 
 
ASB-8 Asbestos Management Plan
Homogeneous Material Identification (Form F)
pdf (11k)
doc (61k)
 
 
ASB-9 Asbestos Management Plan
Listing of Laboratories Utilized for Sample Analysis (Form G)
pdf (8k)
doc (33k)
 
 
ASB-10 Asbestos Management Plan
Summary of Laboratory Samples (Form H)
pdf (10k)
doc (51k)
 
 
ASB-11 Asbestos Management Plan
Continuation Sheet (Form I)
pdf (11k)
doc (33k)
 
 
ASB-12 Asbestos Management Plan
Description of Chain of Command (Form J)
pdf (9k)
doc (33k)
 
 
ASB-13 Asbestos Management Plan
Plan for Reinspection (Form K)
pdf (9k)
doc (33k)
 
 
ASB-14 Asbestos Management Plan
Plan for Operations and Maintenance Activities (Form L)
pdf (10k)
doc (34k)
 
 
ASB-15 Asbestos Management Plan
Plan to Inform (Form M)
pdf (9k)
doc (33k)
 
 
ASB-16 Asbestos Management Plan
Evaluation of Resources (Form N)
pdf (9k)
doc (33k)
 
 
ASB-17 Asbestos Management Plan
Previous/Current Asbestos Abatement Log
(Form O)
pdf (9k)
doc (33k)
 
 
ASB-18 Asbestos Management Plan
Major/Minor Fiber Release Episode Log (Form P)
pdf (10k)
doc (34k)
 
 
ASB-19 Asbestos Management Plan
Statement of Ensurances (Form Q)
pdf (18k)
doc (40k)
 
 
ASB-26 Facility Inspection Worksheet - Asbestos
pdf (16k)
doc (70k)
 
 
ASB-41 Notification of Asbestos Abatement
pdf (14k)
doc (69k)
 
 
BACT-44 Bacteriological Sample Submittal
(Updated November 28, 2016)
pdf (17k)
doc (84k)
 
Instructions for Completing Sample Submittal Forms (pdf 11k)
Instructions for Completing Sample Submittal Forms (doc 26k)
 
BACT-109 Request for Bacterial or Viral Culture or Parasite Identification
pdf (1359k)
 
 
BIR-1 Commission on Brain Injury Research
Qualified Research Institution
Request for Approval
(Updated August 2020)
pdf (1462k)
 
 
CB-2 Fatal/Serious Accident Report (Updated Jan 17)
pdf (52k)
doc (129k)
 
 
CB-11 Application For Certificate of Approval To Operate a Youth Camp
(Updated April 5th, 2022)
pdf (669k)
 
Click here to pay online
 
CB-11A Application For Certificate of Approval To Operate a Youth Camp
(Updated April 5th, 2022)
pdf (644k)
 
Click here to pay online
 
CB-14 Application For Certificate of Approval To Operate a Single Sport Youth Camp
(Updated April 5th, 2022)
pdf (673k)
 
Click here to pay online
 
CB-14A Application For Certificate of Approval To Operate a Single Sport Youth Camp
(Updated April 5th, 2022)
pdf (645k)
 
Click here to pay online
 
CB-15 Annual Accident Report Youth Camp Safety Act
pdf (1601k)
 
 
CB-17 Youth Camp Self-Inspection Report (for Youth Camp Operators)
pdf (23k)
doc (125k)
 
 
CB-18 Youth Camp Safety Detailed Data Sheet (for Local Health Inspectors)
pdf (69k)
doc (224k)
 
 
CB-19 Youth Camp Safety Detailed Data Sheet (for Youth Camp Operators)
pdf (74k)
doc (319k)
 
 
CB-20 Certification for the Replacement of Main Drain Covers in Pool/Spa
pdf (20k)
doc (55k)
 
 
CCR-27 Donation Mail-In Record
pdf (8k)
doc (33k)
 
 
CDC-2 Report of Rabies Postexposure Treatment
pdf (15k)
doc (61k)
 
 
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-CNHGQ (1022k)
 
 
CDC-LCR Listeria Case Report
(Updated September, 2016)
pdf (280k)
 
 
CDC-MIS Multisystem Inflammatory Syndrome Associated with COVID-19: Case Report Form
pdf (957k)
 
 
CDS-1 For Reporting Reportable Communicable Diseases
pdf (17k)
doc (86k)
 
 
CDS-6 Amoebiasis Report  
This form has been removed.
 
CDS-7 Babesiosis Report
pdf (16k)
doc (57k)
 
 
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 (97k)
 
 
CDS-12 Patient Symptoms Line Listing (Gastrointestinal Infection)
pdf (13k)
doc (175k)
 
 
CDS-13 Food-Specific Attack Rate Worksheet
pdf (10k)
doc (31k)
 
 
CDS-14 Lyme Disease Case Investigation
(Updated August 17, 2017)
pdf (262k)
doc (55k)
 
Use PDF (NEW!) for electronic AND hand-written completion. Word version contains instructions.
 
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
(Updated 06-17-2021)
pdf (527k)
 
New Fillable PDF!
 
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-25 Avian Influenza Screening Information
pdf (19k)
doc (66k)
 
 
CDS-26 Speakers' Bureau Request
pdf (10k)
doc (31k)
 
 
CDS-30 Outbreak Report for Long Term Care and Other Institutions
pdf (27k)
doc (139k)
 
Instructions (pdf 20k)
Instructions (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-34 Scabies Case Line List: Residents
pdf (11k)
doc (80k)
 
 
CDS-35 Scabies Case Line List: Staff
pdf (11k)
doc (75k)
 
 
CDS-36 Investigation/Outbreak Intake Record
pdf (14k)
doc (55k)
 
 
CDS-37 Hepatitis B Case Report
pdf (19k)
doc (91k)
 
 
CDS-38 Outbreak Report for Child Care, School and Camp Settings
pdf (24k)
doc (122k)
 
 
CDS-40 STEC Surveillance Case Report
pdf (804k)
doc (97k)
 
 
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)

pdf (264k)
doc (31k)
 
 
CEHS-2 Child Care Center - Indoor Environmental Health Assessment Form B: Historical and Current Uses of Building and Site
pdf (15k)
doc (51k)
 
 
CEHS-3 Child Care Center - Indoor Environmental Health Assessment Form C: Descriptions and Conditions of Building Components
pdf (11k)
doc (34k)
 
 
CEHS-4 Child Care Center - Indoor Environmental Health Assessment Form D: Description of Heating and Cooling Systems
pdf (9k)
doc (32k)
 
 
CEHS-5 Child Care Center - Indoor Environmental Health Assessment Form E: Water and Sewer Information
pdf (9k)
doc (31k)
 
 
CEHS-6 Child Care Center - Indoor Environmental Health Assessment Form F: Hazardous Substances and Vapor Intrusion
pdf (23k)
doc (60k)
 
 
CEHS-7 Child Care Center - Indoor Environmental Health Assessment Form G: Summary of Testing and Evaluation Results
pdf (13k)
doc (79k)
 
 
CEHS-8 Child Care Center - Indoor Environmental Health Assessment Form H: Assessment Summary, Conclusions, Recommendations and Corrective Actions
pdf (12k)
doc (43k)
 
 
CEHS-9 Indoor Environmental Consultant License Application
pdf (20k)
doc (59k)
 
 
CEHS-10 Employee Qualifications: Lead Inspectors/Risk Assessor and Evaluation Contractor Information
pdf (16k)
doc (83k)
 
 
CEHS-11 Employee Qualifications: Asbestos Inspectors
pdf (17k)
doc (99k)
 
 
CEHS-12 Employee Qualifications: General Indoor Environmental Health Assessor
pdf (12k)
doc (49k)
 
 
CEHS-13 Consultant/Employee Certification
pdf (12k)
doc (31k)
 
 
CEHS-14 Employee Qualifications: Radon Certification Information
pdf (16k)
doc (84k)
 
 
CEHS-15 Child Care Center - DOH Subsequent Notification
(Updated April 2018)

Submit Online (preferred method)

pdf (194k)
 
 
CEHS-16 Indoor Environmental Consultant License Renewal Application
pdf (78k)
doc (62k)
 
 
CEHS-17 Statement of Education and Experience Requirements
Lead Inspector / Risk Assessor
pdf (9k)
doc (43k)
 
 
CEHS-18 Statement of Education and Experience Requirements
Supervisor for Housing and Public Buildings
pdf (8k)
doc (43k)
 
 
CEHS-19 Statement of Education and Experience Requirements
Supervisor for Commercial Buildings and Superstructures
pdf (8k)
doc (42k)
 
 
CEOH-1 Checklist for Public Recreational Bathing Facilities (Updated Jan 17)
pdf (160k)
doc (104k)
 
 
CEOH-2 Notification of Non-Friable Asbestos Work Activities
pdf (347k)
 
 
CEOH-3 Notification of Non-Friable Asbestos Work Activities Related to Superstorm Sandy
pdf (13k)
doc (60k)
 
 
CEOH-4 Contractor Information for Non-Friable Asbestos Work Activities
Exemption Request
pdf (869k)
 
 
CES-4 Request for Level A - Aggregate Data
pdf (13k)
doc (51k)
 
 
CES-12 Hematology/Oncology Physician Report
pdf (13k)
doc (59k)
 
 
CES-14 Radiation Therapy Facility Report Form
pdf (13k)
doc (58k)
 
 
CES-15 Ambulatory Surgery Center Report Form
pdf (13k)
doc (57k)
 
 
CES-17 Dentist Report Form
pdf (13k)
doc (57k)
 
 
CES-18 Laboratory Report Form
pdf (13k)
doc (57k)
 
 
CES-40 Physician Report Form (Non-Hospital Source)
pdf (13k)
doc (57k)
 
 
CFO-1 Application for Cottage Food Operator Permit
(Updated October 6, 2021)
pdf (2154k)
 
Instructions (339k)
 
CH-2 Child Health Record
pdf (20k)
doc (142k)
 
 
CH-2A Child Health Conference - Health Assessment (Infancy: 2-6 Weeks)
pdf (19k)
doc (72k)
 
 
CH-2B Child Health Conference - Health Assessment (Infancy: 2 Months)
pdf (19k)
doc (70k)
 
 
CH-2C Child Health Conference - Health Assessment (Infancy: 4 Months)
pdf (19k)
doc (66k)
 
 
CH-2D Child Health Conference - Health Assessment (Infancy: 6 Months)
pdf (19k)
doc (72k)
 
 
CH-2E Child Health Conference - Health Assessment (Infancy: 9 Months)
pdf (19k)
doc (71k)
 
 
CH-2F Child Health Conference - Health Assessment (Infancy: 12 Months)
pdf (19k)
doc (70k)
 
 
CH-2G Child Health Conference - Health Assessment (Childhood: 15 Months)
pdf (19k)
doc (69k)
 
 
CH-2H Child Health Conference - Health Assessment (Childhood: 18 Months)
pdf (18k)
doc (69k)
 
 
CH-2I Child Health Conference - Health Assessment (Childhood: 2 Years)
pdf (29k)
doc (72k)
 
 
CH-2J Child Health Conference - Health Assessment (Childhood: 3 Years)
pdf (19k)
doc (71k)
 
 
CH-2K Child Health Conference - Health Assessment (Childhood: 4 Years)
pdf (19k)
doc (71k)
 
 
CH-2L Child Health Conference - Health Assessment (Childhood: 5 Years)
pdf (19k)
doc (71k)
 
 
CH-2M Child Health Conference - Health Assessment (Childhood: 6 Years)
pdf (19k)
doc (69k)
 
 
CH-2N Child Health Conference - Health Assessment (Childhood: 7 Years)
pdf (18k)
doc (69k)
 
 
CH-2O Child Health Conference - Health Assessment (Childhood: 8 Years)
pdf (18k)
doc (69k)
 
 
CH-2P Child Health Conference - Health Assessment (Childhood: 9 Years)
pdf (19k)
doc (65k)
 
 
CH-2Q Child Health Conference - Health Assessment (Childhood: 10-12 Yrs)
pdf (19k)
doc (72k)
 
 
CH-2R Child Health Conference - Health Assessment (Childhood: 13-15 Yrs)
pdf (19k)
doc (73k)
 
 
CH-2S Child Health Conference - Health Assessment (Childhood: 16-20 Yrs)
pdf (18k)
doc (70k)
 
 
CH-5 Child Health Conference Encounter Record
pdf (35k)
doc (35k)
 
 
CH-7 Child Health Services Quarterly Summary Report
pdf (35k)
doc (70k)
 
Instructions (pdf 28k)
Instructions (doc 33k)
 
CH-8 Patient Referral
pdf (38k)
doc (31k)
 
 
CH-14 Universal Child Health Record
(Contact Child & Adolescent Health Program at 609-292-5666 for more information.)
(Updated October 6, 2017)
pdf (49k)
doc (28k)
 
Instructions (doc 34k)
Instructions (pdf 28k)
 
CH-15 Care Plan for Children with Special Health Needs
pdf (29k)
doc (88k)
 
Instruction (pdf 24k)
Instruction (doc 30k)
 
CH-16 Hearing Screening Report
pdf (60k)
doc (82k)
 
 
CHEM-44 Organic and Inorganic Chemistry Sample Submittal
pdf (19k)
doc (100k)
 
Instructions for Completing Sample Submittal Forms (pdf 11k)
Instructions for Completing Sample Submittal Forms (doc 26k)
 
CL-3 Application for a Clinical Laboratory License
(Onsite Testing Only)
(Updated October 10, 2017)
pdf (320k)
doc (71k)
 
Laboratory Personnel Excel Spread Sheet
Instructions for Completing the Application for a Clinical Lab License
(Updated Oct. 10, 2017)
(pdf 41k)
Instructions for Completing the Application for a Clinical Lab License
(Updated Oct. 10, 2017)
(doc 57k)
 
CL-8 Blood Bank Annual Statistics (Out of Hospital and Emergency Only Transfusion Facilities)
pdf (18k)
doc (34k)
 
 
CL-8A Blood Bank Annual Statistics (Hospitals)
pdf (38k)
doc (199k)
 
 
CL-9 Disclosure of Ownership and Control Interest
(Updated October, 2016)
pdf (19k)
doc (56k)
 
 
CL-13 Blood Bank Annual Statistics
(Hematopoietic Progenitor Cell Facilities)
pdf (15k)
doc (29k)
 
 
CL-14 Blood Bank Annual Statistics
(Perioperative Autologous Blood Collection and Administration Facilities)
pdf (17k)
doc (30k)
 
 
CL-16 Application for a Blood Bank License
pdf (37k)
doc (246k)
 
 
CL-17 Blood Bank Annual Statistics (Umbilical Cord Blood Facilities)
pdf (15k)
doc (29k)
 
 
CL-18 Application for a Clinical Laboratory License
(Collection Station Only)
pdf (13k)
doc (43k)
 
 
CL-21 Error/Accident Report
pdf (9k)
doc (33k)
 
 
CL-34 Laboratory Personnel Qualification Appraisal
pdf (18k)
doc (103k)
 
 
CL-40 Blood Bank Personnel Qualification Appraisal
pdf (65k)
doc (79k)
 
 
CL-44 Transfusion Reaction Report
pdf (8k)
doc (31k)
 
 
CL-50 Brokers and Reagent Manufactureres - Annual Statistical Data
pdf (50k)
doc (59k)
 
 
CL-51 Blood Centers - Annual Statistical Data
pdf (29k)
doc (129k)
 
 
CL-58 Blood Bank License Fee
pdf (11k)
doc (28k)
 
 
CMP-1 Request for Funding from Civil Monetary Penalties
pdf (1217k)
 
 
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)
pdf (394k)
doc (465k)
 
 
CN-3 Application for Certificate of Need for Hospital-Related Projects
(Updated December 1, 2016)
pdf (400k)
doc (506k)
 
 
CN-4 Application for Certificate of Need for Designation as a Perinatal Facility
(Updated December 1, 2016)
pdf (276k)
doc (205k)
 
 
CN-6 Project Application for an Adult Day Health Services Facility
(Formerly HFEL-3)
(Updated May, 2016)
pdf (16k)
doc (41k)
 
 
CN-7 Application for New or Amended Acute Care Facility License
(Last Updated November 10th, 2021)
pdf (421k)
 
New fillable PDF form!
Word document no longer available.
Fees for Licensure and Inspection
 
CN-8 Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility
(Formerly HFEL-4)
(Updated May, 2016)
pdf (14k)
doc (38k)
 
 
CN-9 Health Care Facility Inquiry Regarding Health Care Professional (HFEL-9) (updated August 10,2017)
pdf (17k)
doc (23k)
 
Instructions (pdf 38k)
 
CN-10 Annual Report of Megavoltage Radiation Unit
pdf (17k)
doc (60k)
 
 
CN-11 Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership (Formerly HFEL-8)
(Updated May, 2016)
pdf (28k)
doc (127k)
 
Instructions (pdf 15k)
Instructions (doc 31k)
 
CN-19 Certificate of Need Application-Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a)
(Updated December 1, 2016)
pdf (157k)
doc (116k)
 
 
CN-28 Application for Waiver
(Updated November 3rd, 2021)
pdf (168k)
 
New fillable PDF form!
Word document no longer available.
 
CT-11 Records Release Authorization
pdf (23k)
doc (134k)
 
 
CT-11A Records Release Authorization (spanish)
pdf (23k)
doc (21k)
 
 
CT-14 HIV Consent Form (Serology)
pdf (22k)
doc (21k)
 
 
CT-24 HIV Confidential Consent Form (Serology)
pdf (20k)
doc (21k)
 
 
CT-24A HIV Confidential Consent Form (Serology) (spanish)
pdf (20k)
doc (24k)
 
 
CT-28 HIV Consent (Rapid Testing) - Confidential and Anonymous Testing
pdf (10k)
doc (24k)
 
 
CT-28A HIV Consent (Rapid Testing) (Confidential and Anonymous) (spanish)
pdf (12k)
doc (24k)
 
 
CT-28B HIV Consent (Rapid Testing) (Confidential and Anonymous) (Creole)
pdf (10k)
doc (23k)
 
 
CT-29 HIV Consent (Rapid Testing) - Confidential Testing Only
pdf (9k)
doc (23k)
 
 
CT-29A HIV Consent (Rapid Testing) (Confidential Only) (spanish)
pdf (12k)
doc (12k)
 
 
CT-29B HIV Consent (Rapid Testing) (Confidential Only) (Creole)
pdf (10k)
doc (23k)
 
 
DHAS-1 Grant Application Checklist
pdf (65k)
doc (65k)
 
 
DHAS-2 Fringe Benefit Breakdown
pdf (7k)
doc (26k)
 
 
DHAS-8 Application for Eligibility for the HIV Home Care Program
pdf (25k)
doc (113k)
 
Instructions (pdf 18k)
Instructions (doc 29k)
 
DHAS-9 Client Intake Record
pdf (53k)
doc (68k)
 
 
DHAS-10 Physician Certification and Plan of Care
pdf (35k)
doc (36k)
 
 
DHAS-20 Monthly Activity Report
pdf (79k)
doc (90k)
 
 
DHAS-27 Application for Participation in the
AIDS Drug Distribution Program (ADDP) and/or the
Health Insurance Continuation Program (HICP)
pdf (53k)
doc (166k)
 
 
DHAS-34 Renewal Application for Participation in the Health Insurance Continuation Program
pdf (25k)
doc (73k)
 
 
DHAS-35 Title II Reports  
excel 1.51mb
 
DHAS-37 Certification by Physician (ADDP/HICP)
pdf (13k)
doc (41k)
 
 
DHAS-38 Certification by Pharmacist
pdf (17k)
doc (31k)
 
 
DHAS-39 Health Insurance Information
Health Insurance Continuation Program (HICP)
pdf (13k)
doc (51k)
 
 
DHAS-40 Certification of Separation
AIDS Drug Distribution Program and
Health Insurance Continuation Program
pdf (8k)
doc (28k)
 
 
DHAS-43 Confidential Laboratory Report
pdf (1316k)
 
 
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)
pdf (1343k)
 
 
EHS-1 Application for Reciprocal Lead Permit
pdf (501k)
doc (45k)
 
 
EHS-2 Renewal Application for Lead Training Agency Certification
pdf (17k)
doc (51k)
 
 
EHS-4 Initial Application for Asbestos Training Agency Certification
pdf (18k)
doc (71k)
 
 
EHS-5 Renewal Application for Asbestos Training Agency Certification
pdf (59k)
doc (51k)
 
 
EHS-6 Application for Reciprocal Asbestos Accreditation
(Updated April 26th, 2022)
EHS-6 (248k)
 
 
EHS-10 Facility Inspection Worksheet - Lead
pdf (22k)
doc (74k)
 
 
EHS-15 Application for Approval as a NJ Asbestos Course Instructor
pdf (22k)
doc (65k)
 
 
EHS-16 Application for Approval as a NJ Lead Course Instructor/Training Manager
pdf (66k)
doc (69k)
 
 
EHS-21 Lead Training Course Notification
pdf (15k)
doc (40k)
 
 
EHS-22 Application for Lead Permit Worker-Housing and Public Buildings
pdf (26k)
doc (61k)
 
 
EHS-23 Application for Lead Permit Supervisor, Housing and Public Buildings
pdf (417k)
doc (35k)
 
 
EHS-24 Application for Lead Permit Inspector/Risk Assessor
pdf (380k)
doc (38k)
 
 
EHS-25 Application for Lead Permit Planner/Project Designer
pdf (27k)
doc (61k)
 
 
EHS-26 Application for Lead Permit Worker, Commercial Buildings and Superstructures
pdf (27k)
doc (61k)
 
 
EHS-27 Application for Lead Permit Supervisor, Commercial Buildings and Superstructures
pdf (32k)
doc (87k)
 
 
EHS-28 Initial Application for Lead Training Agency Certification
pdf (64k)
doc (77k)
 
 
EHS-29 Application for Replacement of Lead Permit
pdf (35k)
doc (56k)
 
 
EHS-34 Application for Approval to Operate a Body Art Establishment (Permanent) For use by Local Health Department Officials only.
pdf (17k)
doc (72k)
 
 
EHS-35 Application for Approval to Operate a Body Art Establishment (Temporary) For use by Local Health Department Officials only.
pdf (16k)
doc (60k)
 
 
EHS-36 Body Art Infection/Injury Report For use by Local Health Department Officials only.
pdf (33k)
doc (91k)
 
 
EHS-37 Asbestos Training Course Notification
pdf (13k)
doc (39k)
 
 
EHS-38 Lead Training Course Proposal Checklist
pdf (20k)
doc (91k)
 
 
EHS-39 Asbestos Training Course Proposal Checklist
pdf (23k)
doc (76k)
 
 
EHS-40 Hands-on Assessment
Lead Worker - Housing and Public Buildings
pdf (13k)
doc (71k)
 
 
EHS-41 Hands-On Assessment
Lead Worker-Commercial Buildings and Superstructures
pdf (13k)
doc (71k)
 
 
EHS-42 Hands-On Assessment
Lead Inspector / Risk Assessor
pdf (12k)
doc (57k)
 
 
EHS-43 Hands-On Assessment
Lead Supervisor - Housing and Public Buildings
pdf (13k)
doc (80k)
 
 
EHS-44 Hands-On Assessment
Lead Supervisor - Commercial Buildings and Superstructures
pdf (15k)
doc (93k)
 
 
EHS-45 Hands-On Assessment
Lead Planner / Project Designer
pdf (15k)
doc (96k)
 
 
EHS-46 Request for Reciprocity
Verification of Lead Licensure Status with New York State
(Updated October, 2016)
pdf (17k)
doc (41k)
 
 
EMS-10 EMT Verification Report
pdf (12k)
doc (40k)
 
 
EMS-16 Survey Report for Mobility Assistance Vehicles (Sample)
pdf (779k)
 
 
EMS-19 Survey Report for Ambulance (Basic Life Support) (Sample)
pdf (968k)
 
 
EMS-20 Survey Report for Ambulance (Advanced Life Support) (Non-Transport) (Sample)
pdf (953k)
 
 
EMS-21 Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample)
pdf (1076k)
 
 
EMS-24 Quarterly Report of Mobile Intensive Care Program
pdf (56k)
doc (249k)
 
Instructions (pdf 61k)
Instructions (doc 93k)
 
EMS-25 Quarterly Report of Specialty Care Transport Units
pdf (33k)
doc (81k)
 
Instructions (pdf 22k)
Instructions (doc 44k)
 
EMS-26 Quarterly Report for Basic Life Support Ambulances Providing Emergency Response
pdf (30k)
doc (92k)
 
 
EMS-27 Quarterly Report for Air Medical Units
pdf (39k)
doc (116k)
 
 
EMS-28 Emergency Medical Technician
Continuing Education Documentation
(With NJ/PA Logos)
pdf (21k)
doc (60k)
 
 
EMS-28A Emergency Medical Technician
Continuing Education Documentation
(without Logos)
pdf (8k)
doc (33k)
 
 
EMS-38 Staff Roster
pdf (23k)
doc (144k)
 
 
EMS-43 EMT Course Schedule
pdf (1318k)
 
 
EMS-44 Application for Accreditation - Emergency Medical Technician Education Program
pdf (68k)
doc (99k)
 
 
EMS-56 Application for Certification as an Emergency Medical Technician-Basic Instructor
pdf (13k)
doc (45k)
 
 
EMS-57 Basic Life Support (BLS) Application for Provider Recertification
pdf (20k)
doc (80k)
 
 
EMS-60 Advanced Life Support Application for Provider Recertification
pdf (18k)
doc (55k)
 
 
EMS-61 Emergency Medical Technician Training Fund Final Reimbursement Report
pdf (756k)
 
 
EMS-62 Emergency Medical Technician (EMT) Training Fund Certificate of Eligibility for EMT Education
pdf (762k)
 
 
EMS-63 Form A / EMS First Responder
NJ Protocol for Scene Investigations of Infant and Child Deaths
pdf (23k)
doc (109k)
 
 
EMS-64 EMT & Paramedic Clinician Reciprocity Application Verification of EMT & Paramedic Education and Licensure
pdf (894k)
 
 
EMS-65 EMT Training Fund Payment Voucher
pdf (87k)
 
 
EP-5 New Jersey Medical Reserve Corps User Enrollment Request
pdf (14k)
doc (29k)
 
 
F-2 Registration of Drug or Medical Device Manufacturing or Wholesale Drug or Medical Device Business
(Updated May 23, 2022)
pdf (505k)
 
 
F-5 Initial Application for Certification to Sell Bottled Water or Bulk Water
pdf (18k)
doc (79k)
 
 
F-8 Initial Application for License to Operate a Refrigerated Warehouse and/or Locker Plant
pdf (14k)
doc (33k)
 
 
F-9 Initial Application for License to Operate a Non-Alcoholic Beverage Manufacturing Plant
pdf (12k)
doc (33k)
 
 
F-12 Application for Certificate of Free Sale (CFS)
pdf (18k)
doc (41k)
 
Guidelines for Requesting Certificates of Free Sale (Updated November, 2016)
 
F-13 Renewal or Discontinuation Application to Operate a Wholesale Drug or Medical Device Business
(Updated September 29, 2021)
pdf (188k)
 
 
F-17 Application for Permit to Handle Nitrous Oxide
pdf (13k)
doc (34k)
 
 
F-19 Renewal Application to Operate a Refrigerated Warehouse-Locker Plant
(Updated April 26th, 2022)
F-19 (167k)
 
 
F-26 Self-Inspection Checklist (Wholesale)
pdf (23k)
doc (86k)
 
 
F-27 Self-Inspection Checklist (Retail)
pdf (21k)
doc (74k)
 
 
F-29 Initial Application for License to Operate a Wholesale Food-Cosmetic Establishment
pdf (30k)
doc (66k)
 
 
F-30 Satisfactory Placard
pdf (26k)
doc (246k)
 
Note
 
F-31 Unsatisfactory Placard
pdf (26k)
doc (245k)
 
Note
 
F-32 Conditionally Satisfactory Placard
pdf (26k)
doc (247k)
 
Note
 
F-33 Sanitary Inspection Report
pdf (22k)
doc (253k)
 
Note
 
F-35 Retail Food Inspection Report (Local Health Departments)
pdf (33k)
doc (112k)
 
Note
 
F-37 Risk-Based Inspection Report (Local Health Departments)
pdf (27k)
doc (115k)
 
Note
 
F-39 Renewal Application to Operate a Non-Alcoholic Beverage and/or Bottling Plant
(Updated April 26th, 2022)
F-39 (173k)
 
 
F-41 Renewal Application to Operate a Wholesale Food/Cosmetic Establishment
(Updated August 13, 2021)
pdf (166k)
 
New fillable PDF form!
Word document no longer available.
 
F-42 Renewal Application for Certification to Sell Bottled Water or Bulk Water
pdf (21k)
doc (87k)
 
 
F-48 Application for Certification to Handle Oysters, Clams or Mussels
pdf (13k)
doc (38k)
 
 
FHS-16 Initial Uniform Application for Services to Individuals 21 and Under with Developmental Disabilities
pdf (33k)
doc (61k)
 
 
FHS-18 Formal Dispute Resolution Request
pdf (16k)
doc (38k)
 
Formal Dispute Resolution Request Guidance (formerly titled "Program Guidelines") (pdf 28k)
Formal Dispute Resolution Request Guidance (formerly titled "Program Guidelines") (doc 155k)
 
FHS-18A Formal Dispute Resolution Request (Spanish)
(Solicitud de Resolution de Reclamo Formal)
pdf (15k)
doc (41k)
 
(Guia de Solicitud de Resolucion de Reclamo Formal) (pdf 28k)
(Guia de Solicitud de Resolucion de Reclamo Formal) (doc 156k)
 
FHS-19 Withdrawal of Dispute Resolution Request (formerly titled "Withdrawal of Complaint")
pdf (9k)
doc (27k)
 
 
FHS-19A Withdrawal of Complaint (Spanish)
pdf (8k)
doc (28k)
 
 
FHS-22 Request for Technical Assistance
pdf (8k)
doc (29k)
 
 
F-L3 Certificate of Free Sale Package (English) (including F-L3 and F-12 Forms)
pdf (32k)
doc (766k)
 
Guidelines for Requesting Certificates of Free Sale (Updated November, 2016)
 
F-L4 Certificate of Free Sale Package (Spanish) (including F-L4 and F-12 Forms)
pdf (32k)
doc (767k)
 
Guidelines for Requesting Certificates of Free Sale (Updated November, 2016)
 
FM-7 EMPLOYEE IDENTIFICATION (BUILDING/PARKING) MULTIFORM
pdf (1272k)
 
 
FS-5 Report of Expenditures and Request for Reimbursement for Construction Grants
pdf (11k)
doc (11k)
 
 
FS-20A Report of Grant Expenditures
pdf (15k)
doc (80k)
 
Instructions (pdf 15k)
Instructions (doc 25k)
Budget/Cost Categories and Elements of Cost (pdf 10k)
Budget/Cost Categories and Elements of Cost (doc 23k)
 
FS-27 Notification of Licensed Public Accountant
pdf (14k)
doc (53k)
 
Instructions (pdf 20k)
Instructions (doc 25k)
 
FS-40A Personnel Costs and Justification
pdf (17k)
doc (75k)
 
 
FS-40B Consultant Services Costs and Justification
pdf (12k)
doc (44k)
 
 
FS-40C Other Cost Categories and Justification
pdf (12k)
doc (41k)
 
 
FS-45 Grant Progress Report
pdf (11k)
doc (30k)
 
 
FS-57 Budget Revision Request
pdf (14k)
doc (23k)
 
Budget/Cost Categories and Elements of Cost (pdf 11k)
Budget/Cost Categories and Elements of Cost (doc 23k)
Instructions (pdf 9k)
Instructions (doc 23k)
 
FS-63 Statement of Program Income
pdf (12k)
doc (33k)
 
 
FS-77 Application for Mini-Grant Funds
pdf (18k)
doc (60k)
 
 
FS-91 Statement of Interest Earned from Advance Payments Deposited into an Interest Bearing Account
pdf (11k)
doc (31k)
 
 
FS-D4 Instructions for Completion of "Application for Mini-Grant Funds" (FS-77)
pdf (16k)
doc (31k)
 
 
GRANTS Grant Application Package - General
pdf (90k)
doc (321k)
 
 
GRANTS Grant Application Package - Construction Grant (FS-26)
pdf (10k)
doc (35k)
 
 
GRANTS Grant Application Package - Letter of Agreement
pdf (14k)
doc (82k)
 
 
GRANTS Grant Application Package - Multi-Year 2nd and 3rd Year (FS-20)
pdf (19k)
doc (88k)
 
 
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)
 
 
HCQ-3 Daily Patient Care Staffing: Inpatient Units
pdf (17k)
doc (54k)
 
Instructions (pdf 13k)
Instructions (doc 24k)
 
HCQ-3A Daily Patient Care Staffing - Inpatient (Spanish)
pdf (19k)
doc (58k)
 
Instructions (pdf 14k)
Instructions (doc 26k)
 
HCQ-4 Daily Patient Care Staffing: Emergency Department
pdf (10k)
doc (30k)
 
Instructions (pdf 10k)
Instructions (doc 22k)
 
HCQ-4A Daily Patient Care Staffing - Emergency Department (Spanish)
pdf (13k)
doc (32k)
 
Instructions (pdf 13k)
Instructions (doc 25k)
 
HCQ-5 Daily Patient Care Staffing: Post-Anesthesia Care Unit
pdf (10k)
doc (30k)
 
Instructions (pdf 10k)
Instructions (doc 22k)
 
HCQ-5A Daily Patient Care Staffing - Post Anesthesia Care Unit (PACU) (Spanish)
pdf (13k)
doc (32k)
 
Instructions (pdf 13k)
Instructions (doc 25k)
 
HCQ-6 Daily Patient Care Staffing-Other Licensed Health Care Professionals: Hospital-Wide
pdf (10k)
doc (28k)
 
Instructions (pdf 10k)
Instructions (doc 22k)
 
HCQ-6A Daily Patient Care Staffing - Other Licensed Health Care Professionals, Hospital Wide (Spanish)
pdf (11k)
doc (29k)
 
Instructions (pdf 11k)
Instructions (doc 25k)
 
HCQ-7 Cardiac Cathereterization Data Registry
pdf (81k)
doc (252k)
 
Instructions (pdf 1835k)
 
HCQ-8 NJ Acute Stroke Registry
(Updated May 7, 2020)
pdf (961k)
 
Instructions (January 7, 2020) (pdf 1250k)
 
HCQ-9 Open Heart Surgery Risk Stratification Project - Data Collection Form, Version 4.3
(Updated December, 2016)
pdf (31k)
doc (86k)
 
Instructions and Data Specifications
(Updated December, 2016)
(pdf 799k)
 
HCQO-16 Non-Confidential Release
pdf (21k)
doc (27k)
 
 
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-5 (1340k)
 
Instructions (745k)
 
HFEL-6 Resident Care Staffing Report
pdf (10k)
doc (29k)
 
Instructions (pdf 12k)
Instructions (doc 23k)
 
HFEL-7 New Jersey Universal Transfer Form
pdf (21k)
doc (108k)
 
Instructions (pdf 38k)
Instructions (doc 66k)
 
HFEL-8 Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership
(Changed to CN-11, May, 2016)
   
HIP-5 Laboratory PreScreening Worksheet
pdf (126k)
doc (130k)
 
 
IEM-3 Specimens for Newborn Biochemical Screening
pdf (86k)
doc (71k)
 
 
IEM-15 Order form for Initial Newborn Screening Request (IEM-1) Forms
pdf (8k)
doc (27k)
 
 
IMM-3 Annual College Immunization Status Report
(Updated January 25, 2022)
pdf (442k)
 
NEW! Interactive PDF. DOWNLOAD & SAVE this file on your computer, then open in Adobe Reader.
 
IMM-5 Varicella Case Report
pdf (24k)
doc (104k)
 
 
IMM-6 Vaccines for Children Program
Vaccine Usage Report
(Updated April, 2016)
pdf (13k)
doc (30k)
 
 
IMM-7 Annual Immunization Status Report
pdf (917k)
 
Instructions (pdf 244k)
 
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
pdf (39k)
doc (118k)
 
 
IMM-11 Measles Surveillance Worksheet
pdf (36k)
doc (108k)
 
 
IMM-12 Retrospective Immunization Audit / Survey
pdf (14k)
doc (111k)
 
 
IMM-13 Flu Vaccine Tracking Record
pdf (9k)
doc (47k)
 
 
IMM-14 Immunization Audit Report Worksheet
pdf (19k)
doc (94k)
 
Instructions (pdf 175k)
 
IMM-15 Immunization Audit Report
(Updated October 20, 2017)
pdf (185k)
doc (42k)
 
Instructions (pdf 39k)
Immunization Reporting & Auditing Guidelines (pdf 1194k)
 
IMM-16 Provisional Admittance Student Tracking Record
pdf (12k)
doc (41k)
 
 
IMM-18 Vaccines for Children (NJVFC) Program
New Provider Enrollment for Adult Site
(Updated July, 2016)
pdf (32k)
doc (133k)
 
 
IMM-20 Confidential Perinatal Hepatitis-B Case and Contact Report
pdf (21k)
doc (122k)
 
Instructions for Completing the imm-20 Form (pdf 13k)
Instructions for Completing the imm-20 Form (doc 24k)
 
IMM-21 Mumps Surveillance Worksheet
pdf (35k)
doc (146k)
 
 
IMM-22 Tetanus Surveillance Worksheet
pdf (28k)
doc (95k)
 
Instructions (pdf 23k)
Instructions (doc 26k)
 
IMM-23 Meningococcal Disease Case Report
pdf (20k)
doc (99k)
 
 
IMM-24 Pertussis Investigation Record
pdf (30k)
doc (178k)
 
 
IMM-25 Vaccines for Children (VFC) Program
New Provider Agreement for Adult Sites
(Updated March 22, 2017)
pdf (18k)
doc (35k)
 
 
IMM-26 Vaccines for Children (NJVFC) Program
VFC New Provider Enrollment for Pediatric Site
(Updated July, 2016)
pdf (32k)
doc (137k)
 
 
IMM-28 Vaccines for Children (VFC) Program
Patient Eligibility Screening Record
(Updated July, 2016)
pdf (13k)
doc (56k)
 
 
IMM-28A 317 Program
Patient Eligibility Screening Record
(Updated July, 2016)
pdf (12k)
doc (45k)
 
 
IMM-29 New Jersey Immunization Information System (NJIIS)
Request for Change of User Security Authorization/
Request for Password Reset
pdf (144k)
doc (24k)
 
 
IMM-30 Vaccines for Children Program
Provider Disenrollment Request
(Updated April, 2016)
pdf (15k)
doc (52k)
 
 
IMM-31 Insured for Sure User Enrollment
pdf (10k)
doc (31k)
 
 
IMM-32 NJIIS Consent to Participate (English)
pdf (12k)
doc (30k)
 
 
IMM-32A NJIIS Consent to Participate (Spanish)
pdf (12k)
doc (32k)
 
 
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-36 Vaccines for Children (VFC) Program
New Provider Agreement for Pediatric Sites
(Updated March 22, 2017)
pdf (19k)
doc (35k)
 
 
IMM-40 New Jersey Immunization Information System (NJIIS)
Duplicate Record
pdf (130k)
doc (22k)
 
 
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)
Instructions (doc 25k)
 
IMM-43 User Confidentiality Statement for Access to NJIIS/ User Confidentiality Agreement
pdf (14k)
doc (32k)
 
 
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)
 
 
IMM-48 Vaccines for Children Program
Request to Update Provider Information
(Updated April, 2016)
pdf (11k)
doc (36k)
 
 
IMM-49 Yellow Fever Vaccine Program
Application for Certified Yellow Fever Uniform Stamp
pdf (242k)
doc (23k)
 
 
IMM-50 Yellow Fever Vaccine Program
Acknowledgement of Program Requirements
pdf (16k)
doc (32k)
 
 
IMM-51 Yellow Fever Vaccine Program
Designation of Additional Yellow Fever Vaccination Centers
pdf (15k)
doc (44k)
 
 
IMM-52 Yellow Fever Vaccine Program
Change Notification
pdf (198k)
doc (22k)
 
 
IMM-53 Request for Medical Exemption From Mandatory Immunization
pdf (653k)
 
 
IMM-PKG-A Vaccines for Children (NJVFC) Program
New Provider Enrollment Package (Adult)
(Updated March 22, 2017)
pdf (42k)
doc (146k)
 
 
IMM-PKG-P Vaccines for Children (NJVFC) Program
New Provider Enrollment Package (Pediatric)
(Updated March 22, 2017)
pdf (43k)
doc (152k)
 
 
IRB-1 Application for Initial Review
pdf (53k)
doc (178k)
 
 
IRB-2 Application to Continue Human Subjects Research
pdf (34k)
doc (186k)
 
 
IRB-3 Application to Modify Human Subjects Research
pdf (17k)
doc (50k)
 
Instructions (pdf 31k)
Instructions (doc 78k)
 
LAB-3 Request for Microbiological Testing of Food Sample
pdf (16k)
doc (36k)
 
 
LAB-5 CLINICAL Request for Testing of Suspected Pathogens of Public Health Significance and Chain of Custody
pdf (181k)
doc (96k)
 
 
LAB-7 HIV Test Requisition
pdf (8k)
doc (8kk)
 
 
LAB-10 Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT)
pdf (14k)
doc (49k)
 
 
LCS-4 Communicable Disease Alert
pdf (10k)
doc (29k)
 
 
LCS-5 Application for the Addition of Long-Term Care Beds
(Updated May, 2016)
pdf (17k)
doc (39k)
 
 
LCS-8 Facility Reporting Incident Data and Analysis Yield (FRIDAY)
pdf (36k)
doc (142k)
 
 
LCS-9 Application for a Long-Term Care Facility License
(Updated May 23, 2022)
pdf (30k)
 
 
LH-7 Application for Registered Environmental Health Specialist Examination
pdf (60k)
doc (206k)
 
 
LH-8 Application for Health Officer Examination
pdf (52k)
doc (179k)
 
 
LH-9 Uniform Shared Services Agreement (Template) for Local Public Health Services
pdf (18k)
doc (59k)
 
Guidelines for Uniform Shared Public Health Services Agreement (pdf 20k)
Guidelines for Uniform Shared Public Health Services Agreement (doc 26k)
 
LH-12 New Jersey Local Health Report
Account Creation and Access Request
(Updated June 2016)
pdf (106k)
 
Local Health Report Description (pdf 95k)
 
LH-13 Red Book-Local Health Emergency Contact Directory
Account Creation and Access Request
(Updated June 2016)
pdf (92k)
 
Red Book Directory Description (pdf 182k)
 
LP-3 Report of Childhood Blood Lead Analysis by Independent Laboratory (for children 16 years of age and under)
pdf (13k)
doc (32k)
 
 
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 Initial Application for a Milk Plant or a Bulk Milk Hauler Permit
pdf (22k)
doc (64k)
 
 
M-5 Initial Application for License to Manufacture Frozen Desserts
pdf (15k)
doc (38k)
 
 
M-6 Renewal Application to Operate a Frozen Dessert Plant
pdf (16k)
doc (16kk)
 
 
M-7 Application for Temporary Marketing Permit:
Frozen Desserts Manufacturing Plant
pdf (11k)
doc (36k)
 
 
M-8 Renewal Application to Operate a Bulk Tank Unit/Milk Plant
pdf (15k)
doc (43k)
 
 
MAID-2 Mental Health Professional Compliance Form
(Updated October 8th, 2021)
pdf (922k)
 
Click here for additional information
 
MAID-3 Attending Physician Follow Up Form
(Updated October 8th, 2021)
pdf (2048k)
 
Click here for additional information
 
MAID-4 Medication Dispensing Record
(Updated October 15th, 2021)
pdf (993k)
 
Click here for additional information
 
MAID-5 Consulting Physician Compliance Form
(Updated October 8th, 2021)
pdf (927k)
 
Click here for additional information
 
MAID-6 Request for Medication To End My Life in a Humane and Dignified Manner
(Updated October 8th, 2021)
pdf (961k)
 
Click here for additional information
 
MAID-7 Attending Physician Compliance Form
(Updated October 8th, 2021)
pdf (1047k)
 
Click here for additional information
 
MH-A1 Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (MH)
pdf (1620k)
 
 
MMH-1 Chronic Disease Self-Management Program
"Take Control of Your Health"
Pre-Workshop Participant Survey (English)
pdf (20k)
doc (81k)
 
 
MMH-1A Chronic Disease Self-Management Program
"Take Control of Your Health"
Pre-Workshop Participant Survey (Spanish)
pdf (51k)
doc (95k)
 
 
MMH-2 Chronic Disease Self-Management Program
"Take Control of Your Health"
Post-Workshop Participant Survey (English)
pdf (15k)
doc (60k)
 
 
MMH-2A Chronic Disease Self-Management Program
"Take Control of Your Health"
Post-Workshop Participant Survey (Spanish)
pdf (45k)
doc (71k)
 
 
MMH-3 Diabetes Self-Management Program
"Take Control of Your Health"
Pre-Workshop Participant Survey (English)
pdf (84k)
doc (112k)
 
 
MMH-3A Diabetes Self-Management Program
"Take Control of Your Health"
Pre-Workshop Participant Survey (Spanish)
pdf (28k)
doc (133k)
 
 
MMH-4 Diabetes Self-Management Program
"Take Control of Your Health"
Post-Workshop Participant Survey (English)
pdf (83k)
doc (93k)
 
 
MMH-4A Diabetes Self-Management Program
"Take Control of Your Health"
Post-Workshop Participant Survey (Spanish)
pdf (25k)
doc (108k)
 
 
MMH-5 Faithful Families Eating Smart and Moving More
Healthy Food Policy
pdf (34k)
doc (130k)
 
 
MMH-6 Faithful Families Eating Smart and Moving More
Physical Activity Policy
pdf (34k)
doc (130k)
 
 
MMH-7 Faithful Families Eating Smart and Moving More
Participant Entry Survey (English)
pdf (40k)
doc (192k)
 
 
MMH-8 Faithful Families Eating Smart and Moving More
Participant Exit Survey (English)
pdf (38k)
doc (176k)
 
 
MMH-9 Faithful Families Eating Smart and Moving More
Class or Program Evaluation (English)
pdf (27k)
doc (153k)
 
 
MMP-1 Law Enforcement Incident Report
pdf (10k)
doc (34k)
 
 
MS-5 Continuation Sheet
pdf (10k)
doc (36k)
 
 
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-11 Addendum: CMA Training - List of Course Attendees
pdf (14k)
doc (60k)
 
 
NH-1 Application for Nursing Home Administrator License
(Updated September 1, 2021)
pdf (858k)
 
 
NH-5 Sponsor Application for Continuing Education Program Approval for Licensed Nursing Home Administrators
(Updated January, 2017)
pdf (24k)
doc (109k)
 
Letter to Applicant (pdf 21k)
Letter to Applicant (doc 742k)
 
NH-6 Request for Reciprocity
Verification of Out-of-State Licensure Status
(Updated September, 1, 2021)
pdf (737k)
 
 
NH-8 Application for Approval of Administrative Intern Program
(Updated September 1, 2021)
pdf (751k)
 
 
NH-9 Quarterly Progress Report for
Nursing Home Administrative Intern Program
(Updated September 1, 2021)
pdf (794k)
 
 
NH-10 Certification of Program Completion for Nursing Home Administrative Intern Program
(Updated September 1, 2021)
pdf (839k)
 
 
OAS-F2 PDF Download Instructions
pdf (387k)
 
 
OC-8 Medicinal Marijuana Petition
(Form is not currently available for use.)
   
OC-18 Request for Meeting with Commissioner
(Updated February 21, 2017)
pdf (23k)
doc (223k)
 
 
OC-19 Commissioner Event Attendance Request
(Updated September 16, 2021)
pdf (726k)
 
 
OC-34 Government Records Request (OPRA)
pdf (21k)
doc (42k)
 
 
OC-37 Institutional Approval of Intramural Research
pdf (9k)
doc (36k)
 
 
OC-40 IRB Submission Checklist
pdf (13k)
doc (29k)
 
 
OC-41 Agreement for Ethical Conduct of Human Subjects Research
pdf (31k)
doc (101k)
 
 
OC-45 Agreement for Ethical Conduct of Human Subjects Research (Federal Employees)
pdf (20k)
doc (48k)
 
 
OC-51 Notice of Claim of Exemption of Tobacco Retail Establishment
pdf (35k)
doc (85k)
 
 
OC-53 Application for Registration of Exempt Cigar Bar or Lounge
pdf (42k)
doc (93k)
 
 
OC-54 Application for Renewal of Registration of Exempt Cigar Bar or Lounge
pdf (49k)
doc (95k)
 
 
OC-56 NJ Smoke Free Air Act / Complaint
(Updated January 25,2022)
OC-56 (135k)
 
 
OC-58 NJ Smoke Free Air Act / Anonymous Request for Investigation
(Updated January 25,2022)
OC-58 (89k)
 
 
OC-59 Notice - Smoke Free Air Act
(Updated January 25,2022)
OC-59 (259k)
 
 
OCC-1 Sharps Injury Log
pdf (8k)
doc (8k)
 
 
OCC-2 Exposure Incident Report
pdf (10k)
doc (45k)
 
 
OCC-3 Request for Source Individual Evaluation
pdf (11k)
doc (38k)
 
 
OCC-4 Employee Exposure Determination
pdf (8k)
doc (31k)
 
 
OCC-5 Employee Exposure Follow up Record
pdf (8k)
doc (35k)
 
 
OCC-6 Hepatitis B Vaccine Immunization Record
pdf (7k)
doc (32k)
 
 
OCC-8 Hepatitis B Declination Statement
pdf (7k)
doc (24k)
 
 
OCC-9 Employee Education and Training Record
pdf (11k)
doc (31k)
 
 
OCC-12 Public Employees Occupational Safety and Health (PEOSH) Unit Request for On-Site Consultation
pdf (20k)
doc (54k)
 
On-Line Form
 
OCC-15 Cleaning Schedule
pdf (7k)
doc (26k)
 
 
OCC-16 EMS Respiratory Protection Program Evaluation Questionnaire
pdf (11k)
doc (41k)
 
 
OCC-22 Documentation of Respirator Training
pdf (7k)
doc (25k)
 
 
OCC-23 PEOSH Respirator Medical Evaluation Questionnaire
pdf (32k)
doc (158k)
 
 
OCC-24 Firefighter Respirator Medical Evaluation Questionnaire
pdf (34k)
doc (162k)
 
 
OCC-25 Documentation of Medical Evaluation for Respirator Use
pdf (8k)
doc (29k)
 
 
OCC-30 Firefighter Respirator Fit Test Record
pdf (11k)
doc (30k)
 
 
OCC-31 Occupational and Environmental Disease, Injury, or Poisoning Report by Health Care Provider
(Updated December 14, 2016)
pdf (20k)
doc (59k)
 
Additional Information for Completing the OCC-31 Form (New) (pdf 16k)
Additional Information for Completing the OCC-31 Form (New) (doc 28k)
 
OCC-32 EMS Responder Fit Test Record
pdf (7k)
doc (29k)
 
 
OCC-33 Firefighter SCBA After Use/Daily Inspection Checklist
pdf (13k)
doc (89k)
 
 
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
pdf (15k)
doc (48k)
 
 
OCC-37 PEOSH Hazard Communication Standard, Documentation of Training
pdf (10k)
doc (43k)
 
 
OCC-38 PEOSH Hazard Communication Standard
Brief Self-Inspection Checklist
pdf (743k)
 
NEW! fillable PDF form - use Adobe Reader (click to download Reader)
 
OCC-40 Worksheet for Hazardous Chemical List
pdf (109k)
 
NEW! fillable PDF form - use Adobe Reader (click to download Reader)
 
OCC-41 Sample Letter for Requesting Safety Data Sheets (SDS's)
pdf (2676k)
 
NEW! fillable PDF form - use Adobe Reader (click to download Reader)
 
OCC-46 Worker and Community Right to Know Act / Employer Outreach Survey
pdf (14k)
doc (75k)
 
 
OCC-54 Quarterly Report of RTK County Lead Agencies
pdf (12k)
doc (47k)
 
 
OCC-57 Public Employees Occupational Safety and Health (PEOSH) Unit Complaint
pdf (18k)
doc (53k)
 
 
OPSP-1 J-1 Visa Waiver / State Conrad 30 Program - Physician-Primary Care Survey, Initial/Biannual Service Report
pdf (254k)
doc (22k)
 
 
OPSP-2 J-1 Visa Waiver / State Conrad 30 Program - Application for New Jersey
pdf (391k)
doc (32k)
 
 
OPSP-2A Attachment A: Current Medical Staffing at Practice Site
pdf (187k)
doc (18k)
 
 
OPSP-2B Attachment B: Health Care Resources Inventory
pdf (150k)
doc (18k)
 
 
OPSP-2C Attachment C: Facility Current Sliding Fee Scale
pdf (156k)
doc (16k)
 
 
OPSP-2D Attachment D: J-1 Physician Visa Waiver / State Conrad 30 Program - Statements
pdf (170k)
doc (17k)
 
 
OPSP-3 Section 4-1, Health Facility's J-1 Visa Waiver / State Conrad 30 Program - Agreement
pdf (147k)
doc (20k)
 
 
OPSP-4 Section 4-2, Physician J-1 Visa Waiver / State Conrad 30 Program - Affidavit and Agreement
pdf (181k)
doc (22k)
 
 
OPSP-5 Section 5, J-1 Visa Waiver Required Application Enclosures
pdf (175k)
doc (17k)
 
 
OTC-1 American Cancer Society (ACS) Monthly Activity Report
pdf (47k)
doc (262k)
 
 
OTC-2 GASP Monthly Activity Report
pdf (41k)
doc (256k)
 
 
OTC-3 Mom's Quit Connection (MQC) Monthly Activity Report
pdf (32k)
doc (221k)
 
 
OTC-4 Regional Grantee Monthly Activity Report
pdf (36k)
doc (299k)
 
 
PG-1 Requisition for Printing and Graphic Design
(Updated December 5, 2016)
pdf (24k)
doc (58k)
 
 
PHSS-1 Application for Tanning Facilities Registration
(Updated August, 2016)
pdf (20k)
doc (78k)
 
 
PHSS-3 Tanning Facility Inspection Checklist
(Updated August, 2016)
pdf (26k)
doc (56k)
 
 
PHSS-4 Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects
pdf (2053k)
 
Instructions for Completing the PHSS-5 Payment Voucher (pdf 9k)
 
PHSS-6 Confidential Medical Waste Exposure Report
pdf (22k)
doc (57k)
 
 
PSP-1 Questionnaire to Assess Your Exposure Risk for Lead and Mercury (Quicksilver)
pdf (1350k)
 
 
PV 6-93 Payment Voucher (Vendor Invoice)
(Updated May, 2016)
pdf (32k)
doc (74k)
 
Instructions (pdf 8k)
Instructions (doc 20k)
 
RAD-4 Radioanalytical Services Sample Submittal
pdf (25k)
doc (82k)
 
Instructions for Completing Sample Submittal Forms (doc 32k)
Instructions for Completing Sample Submittal Forms (pdf 12k)
 
REG-1 Quarterly Report of Domestic Partnerships Registered
(Updated April 2, 2018)
pdf (22k)
doc (17k)
 
 
REG-2 Delegation of Authority to Receive Certified Copy of Vital Record (Birth/Death)
(Updated December 26, 2017)
pdf (72k)
doc (18k)
 
 
REG-3 Delegation of Authority to Receive Certified Copy
(Marriage/Civil Union)
(Updated December 26, 2017)
pdf (73k)
doc (18k)
 
 
REG-5 Report of No Births, Marriages, Civil Unions, Domestic Partnerships or Fetal Deaths
(Updated April, 2016)
pdf (15k)
doc (27k)
 
 
REG-7E Application for a Certified Copy of a "No Record of Marriage" Statement (English/Spanish)
(Updated November 23, 2016)
pdf (1229k)
 
 
REG-13 Certified Municipal Registrar Recertification Course Tracking Log
(Updated January, 2015)
pdf (13k)
doc (56k)
 
 
REG-14 Disinterment-Transit Permit
pdf (14k)
doc (44k)
 
 
REG-15 Application to Amend a New Jersey Vital Record /
Application for a Certified Copy of Amended Record
(Updated February 7, 2019)
pdf (179k)
doc (32k)
 
 
REG-20 Authorization for Release of Cause of Death
Autorización para la Emision de Causa de Muerte
(Combined English and español)
pdf (18k)
doc (38k)
 
 
REG-23X Template for Electronic Remarriage License and Certificate
[Set up for Use on Traditional Laser Printers]
(New as of March 1, 2017)
doc (47k)
 
 
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)
doc (49k)
 
 
REG-24X Template for Electronic Marriage License and Certificate
[Set up for Use on Traditional Laser Printers]
(Updated March 1, 2017)
doc (55k)
 
 
REG-24X_MFP Template for Electronic Marriage License and Certificate
[Set up for Use on Multifunction Peripheral (MFP) Devices]
(Updated March 1, 2017)
doc (56k)
 
 
REG-25 Notification of Marriage/Civil Union
(Updated November 1, 2016)
pdf (11k)
doc (27k)
 
 
REG-26 Certificate of Fetal Death
(Updated July 19, 2018)
pdf (69k)
doc (36k)
 
 
REG-27A Application for a Non-Genealogical Certification or Certified Copy of a Vital Record
(English, fillable PDF with instructions)
(Updated April 30, 2019)
pdf (391k)
 
 
REG-27B APLICACIÓN PARA COPIAS CERTIFICADAS Ó CERTIFICACIONES DE REGISTROS CIVILES NO-ANCESTRO
(fillable PDF, Español con Instrucciones)
(Updated October 5, 2017)
pdf (301k)
 
 
REG-28A Application for a Genealogical Certification or Certified Copy of a Vital Record
(fillable PDF, English, with instructions)
(Updated May 9, 2018)
pdf (301k)
 
 
REG-28B APLICACIÓN POR UNA COPIA CERTIFICADA Ó CERTIFICACIONES DE UN REGISTRO CIVIL ANCESTRO
(fillable PDF, Español con Instrucciones)
(Updated May 9, 2018)
pdf (325k)
 
 
REG-33 Short Form Birth Certificate
(Replaces the REG-42D (1) and REG-42D (2))
(Updated February 7th, 2022)
REG-33 (52k)
 
 
REG-33b Short Form Birth Certificate Version B
(Replaces the REG-42D (1) and REG-42D (2))
(Updated February 7th, 2022)
REG-33b (62k)
 
 
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)
pdf (16k)
doc (52k)
 
Instructions for Completing REG-34
Amendment to NJ Vital Record Form
(pdf 20k)
Instructions for Completing REG-34
Amendment to NJ Vital Record Form
(doc 28k)
 
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)
pdf (450k)
doc (340k)
 
 
REG-36A New Records System for Birth Parents
Form A, Contact Preference Form
pdf (27k)
doc (62k)
 
 
REG-36B New Records System for Birth Parents
Form B, Family History Information Form
pdf (44k)
doc (172k)
 
 
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)
 
NEW FORM!
Instructions for Local Registrars
(pdf 105k)
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)
 
NEW FORM!
Instructions for Local Registrars
(pdf 105k)
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)
 
NEW FORM!
Instructions for Local Registrars
(pdf 105k)
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)
 
NEW FORM!
Instructions for Local Registrars
(pdf 105k)
The forms are now ONLY available for download on the EDRS System.
 
REG-40 Attestation to Birth Certificate
(Updated November 21, 2016)
pdf (39k)
doc (48k)
 
 
REG-41 Application for an Uncertified Copy of an Adopted Person's Original Birth Record
pdf (18k)
doc (41k)
 
Instructions (pdf 16k)
Instructions (doc 38k)
 
REG-42F(1) Marriage Template (long form with Parents' Names)
for use on REG-42A Certified Copy Paper
(Updated November, 2013)
doc (30k)
 
 
REG-42F(2) Marriage Template (short form without Parents' Names)
for use on REG-42A Certified Copy Paper
(Updated November, 2013)
doc (28k)
 
 
REG-42G Death Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
doc (30k)
 
 
REG-42H Domestic Partnership Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
doc (29k)
 
 
REG-42I (1) Civil Union Template (without Parent Names)
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
doc (27k)
 
 
REG-42I(2) Civil Union Template (with Parent Names)
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
doc (31k)
 
 
REG-42J Remarriage Template
for use on REG-42A Certified Copy Paper
(Updated October, 2013)
doc (29k)
 
 
REG-42K Reaffirmation of Civil Union Template
for use on REG-42A Certified Copy Paper
(Updated April, 2014)
doc (29k)
 
 
REG-43 Transmittal of Court Order of Paternity
(Updated February 7, 2019)
pdf (638k)
 
NEW! Fillable PDF Form
 
REG-44 Report of Adoption
Registrar una Adopción
(Updated February 7, 2019)
pdf (74k)
doc (23k)
 
English Instructions
español Instrucciones
 
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-62 (145k)
 
 
REG-64 Consent for Artificial Insemination
(Updated December, 2015)
pdf (2724k)
 
 
REG-66 Log of Voided Certified Copy Forms
pdf (10k)
doc (57k)
 
 
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)
pdf (14k)
doc (36k)
 
Guidelines (Guia), (English/español) (REG-D34) (pdf 31k)
Guidelines (Guia), (English/español) (REG-D34) (doc 37k)
 
REG-69 Quarterly Report of Non-EDRS Burial Permits Issued
(Updated April 2, 2018)
pdf (22k)
doc (18k)
 
 
REG-77 Application for License: Marriage, Remarriage, Civil Union, or Reaffirmation of Civil Union
(Updated April 8, 2019)
pdf (28k)
doc (28k)
 
 
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)
pdf (140k)
doc (35k)
 
 
REG-D7 Notice of Rights and Obligations of Domestic Partners
pdf (21k)
doc (38k)
 
 
REG-D7A Notice of Rights and Obligations of Domestic Partners (Spanish)
pdf (22k)
doc (42k)
 
 
REG-D30 "Entering into a Marriage or Civil Union in New Jersey" Brochure
(Updated April 20th, 2022)
REG-D30 (160k)
 
 
REG-D30A "Entering into a Marriage or Civil Union in New Jersey" Brochure (Spanish)
(Updated April 20th,2022)
REG-D30a (663k)
 
 
REG-D30B "Entering into a Marriage or Civil Union in New Jersey" Brochure (Russian)
(Updated April 20th, 2022)
REG-D30b (815k)
 
 
REG-D30C "Entering into a Marriage or Civil Union in New Jersey" Brochure (Korean)
(Updated April 20th, 2022)
REG-D30c (701k)
 
 
REG-D33 "Registering a Domestic Partnership in New Jersey" Brochure
pdf (15k)
doc (30k)
 
 
REG-D33A "Registering a Domestic Partnership in New Jersey" Brochure (español)
pdf (23k)
doc (47k)
 
 
REG-D33B "Registering a Domestic Partnership in New Jersey" (Russian)
pdf (121k)
doc (41k)
 
 
REG-D33C "Registering a Domestic Partnership in New Jersey" (Korean)
pdf (120k)
doc (49k)
 
 
REG-D34 Guidelines for Requesting to Place on File a Certificate of Birth Resulting in Stillbirth (English/español)
(Updated November 21, 2016)
pdf (27k)
doc (44k)
 
 
REG-L2 Request Form and Attestation to Amend Sex Designation on a Birth Certificate for an Adult to Reflect Gender Identity
pdf (120k)
 
 
REG-L3 Parent/Guardian Request Form and Attestation to Amend Sex Designation on a Birth Certificate for a Minor to Reflect Gender Identity
pdf (168k)
 
 
SCH-0 Special Child Health Services Registration Form
pdf (184k)
doc (205k)
 
Instructions and Legends (pdf 167k)
Instructions and Legends (doc 57k)
 
SCH-1 Autism Registration
(Updated November 16, 2016)
(This revised form is to be used in place of the SCH-0/SCH-1 combination.)
pdf (30k)
doc (158k)
 
Instructions
(Updated November 16, 2016)
(doc 52k)
Instructions
(Updated November 16, 2016)
(pdf 21k)
 
SCH-2 Newborn Hearing Follow-Up Report
pdf (31k)
doc (77k)
 
Instructions (pdf 21k)
Instructions (doc 32k)
 
SCH-3 Lost to Hearing Follow Up Report
pdf (25k)
doc (63k)
 
 
SCH-6 Critical Congenital Heart Defects Screening Program
Aggregate Report
doc (35k)
 
 
SCH-7 Notice of Availability of Supplemental Newborn Screening
pdf (225k)
 
 
SCH-7A Notice of Availability of Supplemental Newborn Screening (spanish)
pdf (222k)
 
 
SCH-13 Request for Hearing Aids
pdf (29k)
doc (56k)
 
 
SCR Online Spinal Cord Research Grant Applications    
SCR-1 Commission on Spinal Cord Research
Qualified Research Institution
Request for Approval
(Updated November, 2018)
pdf (947k)
 
 
SRD-1 Request for Viral Serology, Culture and Molecular Diagnostics
pdf (710k)
 
Instructions included on page 2 of form.
Map (pdf 37k)
 
SRD-4 Request for Immunological/Isolation Services - Clinical Services Testing Unit
pdf (25k)
doc (52k)
 
 
STD-11 Confidential Sexually Transmitted Disease Report
(Updated Dec, 2018)
pdf (944k)
 
NEW! Fillable PDF Form
 
STD-17 STD Program Medication Request
pdf (31k)
doc (27k)
 
 
SUD-A1 Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (SUD)
pdf (1011k)
 
 
SUD-A2 APPLICATION FOR NEW OR AMENDED RESIDENTIAL SUBSTANCE USE DISORDER TREATMENT FACILITY LICENSE N.J.A.C. 10:161A
doc (242k)
 
 
TB-1 Quarterly Chest Clinic Activity Report
pdf (9k)
doc (31k)
 
 
TB-3 Medication Request Order
(Updated March, 2016)
pdf (14k)
doc (96k)
 
Medication Request Order Instructions
(Updated November, 2016)
(pdf 381k)
 
TB-4 TB Field Referral
pdf (12k)
doc (40k)
 
 
TB-5 Symptom Assessment for Pulmonary Tuberculosis (TB)
pdf (8k)
doc (29k)
 
 
TB-8 Religious Exemption - School TB Testing/Symptom Assessment Form
pdf (9k)
doc (30k)
 
 
TB-9 Statement of Non-Infectiousness for Symptomatic Individual
pdf (9k)
doc (27k)
 
 
TB-10 Statement of Non-Infectiousness for Individual with TB Disease
pdf (9k)
doc (27k)
 
 
TB-41 Record of Contact Interview (Original + 1 Continuation Page)
pdf (23k)
doc (147k)
 
Instructions (pdf 20k)
Instructions (doc 42k)
 
TB-41 Record of Contact Interview (Original + 2 Continuation Pages)
pdf (30k)
doc (224k)
 
Instructions (pdf 20k)
Instructions (doc 42k)
 
TB-41 Record of Contact Interview (Original + 5 Continuation Pages)
pdf (51k)
doc (445k)
 
Instructions (pdf 20k)
Instructions (doc 42k)
 
TB-43 Tuberculosis (TB) Testing Survey Results
pdf (13k)
doc (98k)
 
Instructions (pdf 9k)
Instructions (doc 22k)
 
TB-57 Annual Report of TB Testing in Schools
pdf (11k)
doc (41k)
 
Instructions (pdf 21k)
Instructions (doc 24k)
 
TB-70 New Jersey Tuberculosis Case, Suspect and Status Report
TB-70 (760k)
 
Instructions for Completion of TB-70 Form (577k)
 
VAERS Vaccine Adverse Event Reporting System: Online    
VIR-1 Requisition for Viral Serology
pdf (22k)
doc (39k)
 
Complete per instructions on form
 
VIR-16 Request for Rabies Examination
(Updated April, 2016)
pdf (13k)
doc (57k)
 
Directions/Map to NJDOH Labs (pdf 2805k)
Instructions for Submission of Specimens (packaging and transport) (pdf 199k)
 
VPH-1 Inspection Report of Kennels, Pet Shops, Shelters, and Pounds
pdf (16k)
doc (66k)
 
 
VPH-2 Animal Rescue Organization Registration
pdf (236k)
 
 
VPH-3 List of Licensed Kennels, Pet Shops, Shelters and Pounds
pdf (20k)
doc (41k)
 
Instructions (pdf 9k)
Instructions (doc 22k)
 
VPH-10 Monthly Dog License Report
pdf (13k)
doc (39k)
 
Instructions
(Updated July 2016)
(pdf 12k)
Instructions
(Updated July 2016)
(doc 28k)
 
VPH-11 Notice of Animal Bite and Confinement
pdf (14k)
doc (36k)
 
Instructions (pdf 11k)
Instructions (doc 25k)
 
VPH-20 Certification of Veterinary Supervision of the Disease Control and Health Care Program at a Licensed Animal Facility
(Updated May, 2016)
pdf (8k)
doc (28k)
 
 
VPH-23 Notice of Intent, State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November 28, 2016)
pdf (10k)
doc (33k)
 
Instructions for State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November, 2016)
(pdf 9k)
Instructions for State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November, 2016)
(doc 23k)
Policies and Guidelines for Animal Rabies Vaccination
(Updated November, 2016)
(pdf 11k)
Policies and Guidelines for Animal Rabies Vaccination
(Updated November, 2016)
(doc 26k)
 
VPH-25 State-Sponsored Municipal Rabies Vaccination Clinic Report
(Updated December 7th, 2021)
pdf (9k)
doc (28k)
 
Instructions for State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November, 2016)
(pdf 9k)
Instructions for State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November, 2016)
(doc 23k)
Policies and Guidelines for Animal Rabies Vaccination
(Updated November, 2016)
(pdf 11k)
Policies and Guidelines for Animal Rabies Vaccination
(Updated November, 2016)
(doc 26k)
 
VPH-26 Rabies Vaccination Certificate
pdf (12k)
doc (36k)
 
 
VPH-28 Certificate of Exemption from Rabies Vaccination
pdf (21k)
doc (38k)
 
 
VPH-32 Application for Animal Control Officer Certification
pdf (10k)
doc (28k)
 
 
VPH-35 Rabies Testing Notification Form
VPH-35 (728k)
 
 
W-9 Vendor Questionnaire
pdf (37k)
doc (70k)
 
Instructions (pdf 13k)
Instructions (doc 22k)
 
WIC-6 WIC Vendor Selection Criteria
(Updated 11/8/2017)
pdf (98k)
doc (27k)
 
New Fillable PDF!
 
WIC-8 New Jersey Division of Taxation
Authorization for Release of Tax Return Information
pdf (21k)
doc (742k)
 
 
WIC-11 Medical Documentation for WIC Formula and Approved WIC Foods for Infants, Children and Women
(Updated April, 2016)
pdf (34k)
doc (95k)
 
 
WIC-12 Designation of Infant Formula Manufacturer, Retailer, Wholesaler and Distributor
pdf (14k)
doc (30k)
 
 
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