Additional Health Department Forms

Forms for Public Health and Environmental Laboratories

Clinical Laboratory Licensure and Proficiency Testing Review
Form # Title PDF/WORD Instruction/ Comments
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
doc 57k  
CL-9 Disclosure of Ownership and Control Interest
(Updated October, 2016)
pdf 19k
doc 56k
 
CL-18 Application for a Clinical Laboratory License
(Collection Station Only)
pdf 13k
doc 43k
 
CL-34 Laboratory Personnel Qualification Appraisal pdf 18k
doc 103k
 
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
 
Blood Bank Licensure and Regulatory Compliance
Form # Title PDF/WORD Instruction/ Comments
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-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-21 Error/Accident Report pdf 9k
doc 33k
 
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
 
CLIA Program
Form # Title PDF/WORD Instruction/ Comments
CMS-116 Clinical Laboratory Improvement Amendments (CLIA) Application for Certification  
 
 
Public Health Laboratory Services
Form # Title PDF/WORD Instruction/ Comments
BACT-44 Bacteriological Sample Submittal
(Updated November 28, 2016)
pdf 17k
doc 84k
Instructions for Completing Sample Submittal Forms
pdf 11k
doc 26k  
BACT-109 Request for Bacterial or Viral Culture or Parasite Identification pdf 12k
doc 42k
 
IEM-15 Order form for Initial Newborn Screening Request (IEM-1) Forms pdf 8k
doc 27k
 
LAB-3 Request for Microbiological Testing of Food Sample pdf 16k
doc 36k
 
LAB-5 Request for Testing of Suspected Pathogens of Public Health Significance and Chain of Custody pdf 159k
doc 139k
 
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
 
SRD-1 Request for Immunological/Isolation Services-Viral Testing Unit
(Updated October 2017)
pdf 61k
doc 28k
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
 
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  
Environmental and Chemical Laboratory Services
Form # Title PDF/WORD Instruction/ Comments
BACT-44 Bacteriological Sample Submittal
(Updated November 28, 2016)
pdf 17k
doc 84k
Instructions for Completing Sample Submittal Forms
pdf 11k
doc 26k  
CHEM-44 Organic and Inorganic Chemistry Sample Submittal pdf 19k
doc 100k
Instructions for Completing Sample Submittal Forms
pdf 11k
doc 26k  
PSP-1 Questionnaire to Assess Your Exposure Risk for Lead and Mercury (Quicksilver) pdf 1350k
 
 
RAD-4 Radioanalytical Services Sample Submittal pdf 25k
doc 82k
Instructions for Completing Sample Submittal Forms
doc 32k
pdf 12k  
Go to Public Health and Environmental Laboratories     Additional Health Department Forms