AIDS Drug Distribution Program (ADDP)
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| DHAS-38 |
Certification by Pharmacist |
|
|
| DHSTS-27 |
Application for Participation in the AIDs Drug Distribution Program (ADDP) (Previously DHAS-27)
(Posted February 15th, 2024) |
|
|
| DHSTS-27b |
Addendum to the Application for Participation in the AIDs Drug Distribution Program (ADDP)
(Posted February 15th, 2024) |
|
|
| DHSTS-37 |
Certification by Licensed Healthcare Practitioner (Previously DHAS-37)
(Updated February 15th, 2024) |
|
|
Health Insurance Continuation Program
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| DHAS-38 |
Certification by Pharmacist |
|
|
| DHAS-39 |
Health Insurance Information
Health Insurance Continuation Program (HICP) |
|
|
| DHSTS-27 |
Application for Participation in the AIDs Drug Distribution Program (ADDP) (Previously DHAS-27)
(Posted February 15th, 2024) |
|
|
| DHSTS-27b |
Addendum to the Application for Participation in the AIDs Drug Distribution Program (ADDP)
(Posted February 15th, 2024) |
|
|
| DHSTS-37 |
Certification by Licensed Healthcare Practitioner (Previously DHAS-37)
(Updated February 15th, 2024) |
|
|
HIV Consent Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| 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) |
|
|
Home Health Program
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| DHAS-8 |
Application for Eligibility for the HIV Home Care Program |
|
|
| DHAS-9 |
Client Intake Record |
|
|
Grant Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| DHAS-35 |
Title II Reports |
|
|
Case Reporting
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CDC 50.42A |
Adult HIV Confidential Case Report Form
(Updated April 6th, 2023) |
|
|
| CDC 50.42B |
Pediatric HIV Confidential Case Report Form
(Updated April 6th, 2023) |
|
|
| 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) |
|
|
Tuberculosis Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| LAB-10 |
Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT) |
|
|
| 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)
(Updated December 15th, 2022) |
|
|
| TB-41a |
Record of Contact Interview (Original + 2 Continuation Pages)
(Updated December 15th, 2022) |
|
Instructions (pdf 20k)
|
| TB-41b |
Record of Contact Interview (Original + 5 Continuation Pages)
(Updated December 15th, 2022) |
|
|
| TB-43 |
Tuberculosis (TB) Testing Survey Results |
|
Instructions (pdf 9k)
Instructions (doc 22k)
|
| TB-57 |
Annual Report of TB Testing in Schools |
|
|
| TB-70 |
New Jersey Tuberculosis Case, Suspect and Status Report |
|
Instructions for Completion of TB-70 Form (577k)
|
Sexually Transmitted Diseases
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| STD-11a |
Confidential Syphilis Case Report Form
(Updated September 25th, 2023) |
|
|
| STD-11b |
Confidential Gonorrhea Case Report Form
(Posted March 3rd, 2023) |
|
|
| STD-11c |
Confidential Chlamydia Case Report Form
(Posted March 3rd, 2023) |
|
|
Other
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| HRC-1 |
Harm Reduction Center Registration Application
(Updated July 11th, 2023) |
|
|
| HRC-2 |
Harm Reduction Center Membership Card
(Posted June 19th, 2023) |
|
|
