Additional Health Department Forms

Forms for Communicable Disease Service

CDC Report Forms
Form # Form Name/Title Linked File Instruction/ Comments
CDC-2 Report of Rabies Postexposure Treatment
pdf (15k)
doc (61k)
 
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)
 
Forms for Health Professionals
Form # Form Name/Title Linked File Instruction/ Comments
BACT-109 Request for Bacterial or Viral Culture or Parasite Identification
pdf (1359k)
 
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)
 
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)
 
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)
 
SRD-1 Request for Viral Serology, Culture and Molecular Diagnostics
pdf (710k)
Instructions included on page 2 of form. Map (pdf 37k)  
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)
 
Vaccine Preventable Disease Program
Reporting Forms
Form # Form Name/Title Linked File Instruction/ Comments
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-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-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-48 Vaccines for Children Program
Request to Update Provider Information
(Updated April, 2016)
pdf (11k)
doc (36k)
 
IMM-53 Request for Medical Exemption From Mandatory Immunization
pdf (653k)
 
VAERS Vaccine Adverse Event Reporting System: Online  
NJ Immunization Information System
Form # Form Name/Title Linked File Instruction/ Comments
IMM-6 Vaccines for Children Program
Vaccine Usage Report
(Updated April, 2016)
pdf (13k)
doc (30k)
 
IMM-18 Vaccines for Children (NJVFC) Program
New Provider Enrollment for Adult Site
(Updated July, 2016)
pdf (32k)
doc (133k)
 
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-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-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)
 
VAERS Vaccine Adverse Event Reporting System: Online  
Animal Population Control Program
Form # Form Name/Title Linked File Instruction/ Comments
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)
 
VPH-32 Application for Animal Control Officer Certification
pdf (10k)
doc (28k)
 
Shelter/Pound Survey Form
Form # Form Name/Title Linked File Instruction/ Comments
APC-12 Shelter/Pound Annual Report
pdf (13k)
doc (91k)
Instructions (pdf 13k)
Instructions (doc 32k)
 
Animal Licensing and Confinement Forms
Form # Form Name/Title Linked File Instruction/ Comments
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)
(doc 28k) Instructions
(Updated July 2016)
(pdf 12k)  
VPH-11 Notice of Animal Bite and Confinement
pdf (14k)
doc (36k)
Instructions (doc 25k)
Instructions (pdf 11k)
 
Animal Control and Facility Inspection
Form # Form Name/Title Linked File Instruction/ Comments
VPH-1 Inspection Report of Kennels, Pet Shops, Shelters, and Pounds
pdf (16k)
doc (66k)
 
VPH-2 Animal Rescue Organization Registration
pdf (236k)
 
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)
 
State/Municipal-Sponsored Rabies Vaccination
Form # Form Name/Title Linked File Instruction/ Comments
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-35 Rabies Testing Notification Form
VPH-35 (728k)
 
Go to Communicable Disease Service     Additional Health Department Forms