Additional Health Department Forms

Forms for HIV, STD and TB Services

AIDS Drug Distribution Program (ADDP)
Form # Form Name/Title Linked File Instruction/ Comments
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-37 Certification by Physician (ADDP/HICP)
pdf (13k)
doc (41k)
 
DHAS-38 Certification by Pharmacist
pdf (17k)
doc (31k)
 
DHAS-40 Certification of Separation
AIDS Drug Distribution Program and
Health Insurance Continuation Program
pdf (8k)
doc (28k)
 
Health Insurance Continuation Program
Form # Form Name/Title Linked File Instruction/ Comments
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-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)
 
HIV Consent Forms
Form # Form Name/Title Linked File Instruction/ Comments
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)
 
Home Health Program
Form # Form Name/Title Linked File Instruction/ Comments
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)
 
Grant Forms
Form # Form Name/Title Linked File Instruction/ Comments
DHAS-1 Grant Application Checklist
pdf (65k)
doc (65k)
 
DHAS-2 Fringe Benefit Breakdown
pdf (7k)
doc (26k)
 
DHAS-35 Title II Reports
excel 1.51mb
 
Case Reporting
Form # Form Name/Title Linked File Instruction/ Comments
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)  
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)
 
Tuberculosis Forms
Form # Form Name/Title Linked File Instruction/ Comments
LAB-10 Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT)
pdf (14k)
doc (49k)
 
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)  
Sexually Transmitted Diseases
Form # Form Name/Title Linked File Instruction/ Comments
STD-11 Confidential Sexually Transmitted Disease Report
(Updated July 8, 2022)
STD-11 (441k)
 
STD-17 STD Program Medication Request
pdf (31k)
doc (27k)
 
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