Health Department Forms

<!DOCTYPE html> <html xmlns="http://www.w3.org/1999/xhtml"> <head><title> Health Department Forms </title><meta name="Keywords" content="health, form, forms" /><meta name="Description" content=" Health Department Forms" /><meta http-equiv="X-UA-Compatible" content="IE=edge" /> <script src="../Js/main.js"></script>  <link href="https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/3.1.1/css/bootstrap.min.css" rel="stylesheet" />  <link href="/style/styles.css" rel="stylesheet" type="text/css" />  <link href="/style/liteAccordion.css" rel="stylesheet" /> <script src="https://ajax.googleapis.com/ajax/libs/jquery/1.11.0/jquery.min.js"></script> <script src="https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/3.1.1/js/bootstrap.js"></script> <script src="/scripts/jquery.cookie.js" type="text/javascript"></script> <script src="/js/jquery.colorbox.js"></script>  <script> var polyfilter_scriptpath = "/js/" </script> <script src="/js/bootstrap-menu-fix.js" type="text/javascript"></script>  <style> @import url(https://fonts.googleapis.com/css?family=Open+Sans:300italic,400italic,600italic,700italic,800italic,400,300,600,700,800|Crimson+Text:400,600); </style>     <script src="/scripts/commonFunctions.js" type="text/javascript"></script> <link href="../style/print_yc.css" rel="stylesheet" type="text/css" /><link href="../style/facility.css" rel="stylesheet" type="text/css" /> <style type="text/css"> .FormatRadioButtonList label { margin-left: 5px; vertical-align:middle; } </style> </head> <body class="landing-page-a app-wrapper"> <div class="container" id="centerwrapper"> <section id="content">  <section id="header"> <div class="clickable">  <a href="http://www.nj.gov/health/" id="stateLogoLink"> <div id="stateLogo"> <img src="/template-images/nj_state_seal.png"> <div id="state"><span class="big">S</span>tate of <span class="big">N</span>ew <span class="big">J</span>ersey</div> <div id="dept"><span class="big">D</span>epartment of <span class="big">H</span>ealth</div> </div> </a> <div id="stateLinks"> <div class="gov">Governor Phil Murphy · Lt. Governor Tahesha Way</div> <div class="links"> <a href="https://www.nj.gov/">NJ Home</a> | <a href="https://www.nj.gov/nj/gov/njgov/alphaserv.html">Services A to Z</a> | <a href="https://www.nj.gov/nj/gov/deptserv/">Departments/Agencies</a> | <a href="https://www.nj.gov/faqs/">FAQs</a> </div> <form id="seek" name="seek" method="get" action="https://search.state.nj.us/query.html"> <label class="" accesskey="s" title="enter keyword here" for="qt">Search</label> <select class="selectbox" id="qp" name="qp"> <option selected="selected" value="">All of NJ</option> <option value="+url:www.state.nj.us/health/">This Site</option> </select> <label class="hidden" accesskey="c" for="qp">select</label> <input type="text" class="searchbox" size="8" id="qt" name="qt"> <select class="selectbox" id="qs" name="qs"> <option selected="selected" value="&$qs">All File Types</option> <option value="+doctype:text/html">Web Pages Only </option> <option value="-doctype:text/html"> Documents Only </option> </select> <input type="submit" border="0" class="submit_search green element" alt="submit" id="submit_search" name="submit search" value="submit"> </form> </div> <br clear="all"> <a href="https://www.nj.gov/health/"> <div id="topLeft"> <div><img src="/template-images/njdoh_svgnew.png"/></div> </div> </a>  </div> </section>  </section> </div> <div class="container wide darkblue "> <section id="content"> <div class="container" id="masthead"> <h1><a href="" class="link-back">Health Department Forms</a></h1> </div> </section> </div> <div class="container clearfix" id="content"> <section id="content"> <div id="app-Wrapper" class=""> <form method="post" action="./index.aspx" onsubmit="javascript:return WebForm_OnSubmit();" id="mainpage"> <div class="aspNetHidden"> <input type="hidden" name="__EVENTTARGET" id="__EVENTTARGET" value="" /> <input type="hidden" name="__EVENTARGUMENT" id="__EVENTARGUMENT" value="" /> <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="/wEPDwULLTE4NTE5MjY2ODIPZBYCZg9kFgICBg9kFgICAQ9kFgICCQ8PFgIeBFRleHRlZGRkNECzmTJZd3rBga1ZUOKX6a+8I5Y=" /> </div> <script type="text/javascript"> //<![CDATA[ var theForm = document.forms['mainpage']; if (!theForm) { theForm = document.mainpage; } function __doPostBack(eventTarget, eventArgument) { if (!theForm.onsubmit || (theForm.onsubmit() != false)) { theForm.__EVENTTARGET.value = eventTarget; theForm.__EVENTARGUMENT.value = eventArgument; theForm.submit(); } } //]]> </script> <script src="/forms/WebResource.axd?d=0QwA6mKuI8ICtQvkvzpfmfIgi-COm6taUHx2Y_6YCeJHmXsvrwCqd2_LMuQ1DmicJMj2R5ooZTUSaR-LSzmEyIcuyyI1&t=637814473746327080" type="text/javascript"></script> <script src="/forms/WebResource.axd?d=hfPMvRWBqAyA9QvFi5SdwGGPklSpk3wefpbivkkB5XJGbIFFIAm1ZIlYJJRNQ5ue9LT7QrWfY26Yg3osuwkkIxnC1oMx5UGryq5kppDxWqK-PiSO0&t=637814473746327080" type="text/javascript"></script> <script type="text/javascript"> //<![CDATA[ function WebForm_OnSubmit() { if (typeof(ValidatorOnSubmit) == "function" && ValidatorOnSubmit() == false) return false; return true; } //]]> </script> <div class="aspNetHidden"> <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="B372B39A" /> <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="/wEdAAQh9Txvv7nG44SqR1fSz9NMvve3qHTc0+O+zbt1FH+eMHXlnF6575MENzzL89IVRCBulHtEYvSfNgtq37ri3V6GjanHcqMcWpBVTyK6qRl0vrHQJVc=" /> </div> <table style="text-align:center; margin-left:auto; margin-right:auto; width:100%"> <tr> <td> <script type="text/javascript"> function clickButton(e, buttonid) { var evt = e ? e : window.event; var bt = document.getElementById(buttonid); if (bt) { if (evt.keyCode == 13) { bt.click(); return false; } } } </script> <table style="width:100%" border="0"> <tr> <td class="black13_bold">The forms are listed alphabetically by form number in PDF and Word template format.</td> <td style="text-align:right"></td> </tr> </table> <br /> <table style="width:100%" border="0"> <tr> <td style="text-align:left"><b>For Search:</b> Enter keywords for the search separated by '<span style="font-weight:bold">,</span>', e.g. vaccine, vaccination. The <b>maximum keywords you can search is four</b> for each search.</td> </tr> <tr> <td style="text-align:left; vertical-align:baseline"> <input name="ctl00$ContentPlaceHolder1$Keywords" type="text" id="ContentPlaceHolder1_Keywords" style="width:500px;" />  <input type="submit" name="ctl00$ContentPlaceHolder1$search" value="Search" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$ContentPlaceHolder1$search", "", true, "", "", false, false))" id="ContentPlaceHolder1_search" />  <input type="submit" name="ctl00$ContentPlaceHolder1$clear" value="Clear Search" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$ContentPlaceHolder1$clear", "", true, "", "", false, false))" id="ContentPlaceHolder1_clear" /> <span id="ContentPlaceHolder1_RegularExpressionValidator1" style="visibility:hidden;">Invalid search characters.</span></td> </tr> </table> <br /> <table style="width:100%" border="0"> <tr><td style="text-align:center" class="burg13bold"><span id="ContentPlaceHolder1_msg"></span></td></tr> </table> <table style="width:100%; border-spacing:3px;border-collapse:separate" border="1" id="main_table"> <tr class=" black13_bold" style="height:35px"> <td style="width:8%; text-align:left">Form Number</td> <td style="width:35%; text-align:left" class="header">Form Name/Title</td> <td style="width:20%" class="header">Linked File</td> <td style="width:27%; text-align:left" class="header">Instructions</td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">AAS-5<a id="aas-5" name="aas-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Facility Inspection Worksheet<br>(Resident Rights, Physical Plant and Environment, Safety, Dietary Services)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (32k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-5.dot','name','600','400','yes','yes','no','no')>doc</a> (95k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">AAS-11<a id="aas-11" name="aas-11"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Nurse Staffing Report<br><i>(Updated August 5th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-11.pdf','name','600','400','yes','yes','no','no')>AAS-11</a> (309k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">AAS-12<a id="aas-12" name="aas-12"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Supplementary Nurse Staffing Report<br><i>(Posted August 5th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-12.pdf','name','600','400','yes','yes','no','no')>AAS-12</a> (924k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">AAS-22<a id="aas-22" name="aas-22"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Adult Medical Day Care Inspection Information</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-22.pdf','name','600','400','yes','yes','no','no')>pdf</a> (31k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-22.dot','name','600','400','yes','yes','no','no')>doc</a> (73k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">AAS-23<a id="aas-23" name="aas-23"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Pediatric Medical Day Care Inspection Information</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-23.pdf','name','600','400','yes','yes','no','no')>pdf</a> (25k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-23.dot','name','600','400','yes','yes','no','no')>doc</a> (62k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">AAS-24<a id="aas-24" name="aas-24"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Affidavit of Compliance Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-24.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-24.dot','name','600','400','yes','yes','no','no')>doc</a> (74k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">AAS-40<a id="aas-40" name="aas-40"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Affidavit of Compliance with N. J. Licensure Standards for Adult Day Health Care Facilities</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-40.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-40.dot','name','600','400','yes','yes','no','no')>doc</a> (42k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">AAS-45<a id="aas-45" name="aas-45"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Reportable Event Record/Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-45.pdf','name','600','400','yes','yes','no','no')>pdf</a> (16k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-45.dot','name','600','400','yes','yes','no','no')>doc</a> (56k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">AAS-55<a id="aas-55" name="aas-55"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Declaration of Compliance with Advisory Standards</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-55.pdf','name','600','400','yes','yes','no','no')>pdf</a> (67k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-55.dot','name','600','400','yes','yes','no','no')>doc</a> (175k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">AAS-59<a id="aas-59" name="aas-59"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Medical Day Inspection Information</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-59.pdf','name','600','400','yes','yes','no','no')>pdf</a> (29k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-59.dot','name','600','400','yes','yes','no','no')>doc</a> (77k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">AAS-60<a id="aas-60" name="aas-60"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Consumer Resident/Patient Complaint Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-60.PDF','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-60.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">AAS-61<a id="aas-61" name="aas-61"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Medical Day Care Assessment and Survey<br>Exit Conference Guide</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-61.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-61.dot','name','600','400','yes','yes','no','no')>doc</a> (47k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">AAS-80<a id="aas-80" name="aas-80"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Assisted Living Assessment and Survey<br>Exit Conference Guide</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-80.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1322k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">AAS-81<a id="aas-81" name="aas-81"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Assisted Living Entrance Guide</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-81.pdf','name','600','400','yes','yes','no','no')>pdf</a> (781k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">AAS-84<a id="aas-84" name="aas-84"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Affidavit of Compliance with N. J. Licensure Standards for Pediatric Medical Day Care Facilities</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-84.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/aas-84.dot','name','600','400','yes','yes','no','no')>doc</a> (39k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="ach" name="ach"/><a href="subforms.aspx?pro=hf" target=_blank>ACH</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NJ Acute Care Hospitals Cost Reports<br><i>(Updated May 14th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ach.pdf','name','600','400','yes','yes','no','no')>ACH</a> (962k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-16" name="acs-16"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-16.dot" target=_blank>ACS-16</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Workshop Information Cover Sheet</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-17" name="acs-17"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-17.dot" target=_blank>ACS-17</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Notification of Upcoming Workshop</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-18" name="acs-18"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-18.dot" target=_blank>ACS-18</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Attendance Log</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-19" name="acs-19"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-19.dot" target=_blank>ACS-19</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Participant Information Survey</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-19a" name="acs-19a"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-19a.dot" target=_blank>ACS-19A</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Participant Information Survey (Spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-20" name="acs-20"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-20.dot" target=_blank>ACS-20</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Workshop Evaluation</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-20a" name="acs-20a"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-20a.dot" target=_blank>ACS-20A</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Workshop Evaluation (Spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-21" name="acs-21"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-21.doc" target=_blank>ACS-21</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Participant Certificate of Completion Template</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-21a" name="acs-21a"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-21a.doc" target=_blank>ACS-21A</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Participant Certificate of Completion Template (Spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-22" name="acs-22"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-22.dot" target=_blank>ACS-22</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Peer Leader Agreement</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-23" name="acs-23"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-23.dot" target=_blank>ACS-23</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Peer Leader Contact Information and Training Verification</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-24" name="acs-24"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-24.dot" target=_blank>ACS-24</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Notification of Upcoming Peer Leader Training</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-27" name="acs-27"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-27.dot" target=_blank>ACS-27</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Peer Leader Training Certificate of Completion</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-28" name="acs-28"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-28.dot" target=_blank>ACS-28</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Master Trainer Checklist for Observing Peer Leaders</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-29" name="acs-29"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-29.dot" target=_blank>ACS-29</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Group Leader Script (English)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-29a" name="acs-29a"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-29a.dot" target=_blank>ACS-29A</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Group Leader Script (Spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="acs-32" name="acs-32"/><a href="http://www.nj.gov/humanservices/doas/forms/acs-32.dot" target=_blank>ACS-32</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Take Control of Your Health<br>Workshop Checklist Summary</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="acs-33" name="acs-33"/><a href="http://www.nj.gov/humanservices/doas/forms/ACS-33.docx" target=_blank>ACS-33</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Take Control of Your Health<br>Non-Disclosure Agreement</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">APC-4<a id="apc-4" name="apc-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Veterinarian Co-Payment Fee Submission</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-4.dot','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">APC-5<a id="apc-5" name="apc-5"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application and Consent for Sterilization of Pets</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-5.dot','name','600','400','yes','yes','no','no')>doc</a> (44k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">APC-6<a id="apc-6" name="apc-6"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Animal Population Control Program<br>Veterinarian's Agreement (Updated April 23, 2018)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-6.pdf','name','600','400','yes','yes','no','no')>APC-6</a> (799k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">APC-7<a id="apc-7" name="apc-7"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Payment Voucher / Veterinarian Reimbursement</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (28k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-7.dot','name','600','400','yes','yes','no','no')>doc</a> (3063k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">APC-11<a id="apc-11" name="apc-11"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Animal Population Control Program Proxy Authorization</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-11.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-11.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">APC-12<a id="apc-12" name="apc-12"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Shelter/Pound Annual Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-12.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-12.dot','name','600','400','yes','yes','no','no')>doc</a> (91k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-12instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 13k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/apc-12instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 32k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ARR<a id="arr" name="arr"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Rehabilitative Hospital and Special Hospital subject to a $10 Adjusted Admission Assessment</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/arr.pdf','name','600','400','yes','yes','no','no')>pdf</a> (755k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/arr_instr1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 86k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-3<a id="asb-3" name="asb-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan<br>Inspection Cover Sheet (Form A)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-3.dot','name','600','400','yes','yes','no','no')>doc</a> (42k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-3instr_1.pdf','name','600','400','yes','yes','no','no')>Guide to Completing Asbestos Management Plan Forms</a> (pdf 34k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-3instr_1.doc','name','600','400','yes','yes','no','no')>Guide to Completing Asbestos Management Plan Forms</a> (doc 45k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-4<a id="asb-4" name="asb-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Asbestos Management Plan<br>Room/Functional Space Inspection (Form B)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-4.dot','name','600','400','yes','yes','no','no')>doc</a> (50k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-5<a id="asb-5" name="asb-5"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan<br>Cover Sheet (Form C)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-5.dot','name','600','400','yes','yes','no','no')>doc</a> (53k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-6<a id="asb-6" name="asb-6"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Asbestos Management Plan, Room/Functional Space Inspection<br>Response Actions (Form D)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-6.dot','name','600','400','yes','yes','no','no')>doc</a> (65k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-7<a id="asb-7" name="asb-7"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan<br>Room/Functional Space<br>Boiler Room Response Actions (Form E)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-7.dot','name','600','400','yes','yes','no','no')>doc</a> (68k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-8<a id="asb-8" name="asb-8"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Asbestos Management Plan<br>Homogeneous Material Identification (Form F)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-8.dot','name','600','400','yes','yes','no','no')>doc</a> (61k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-9<a id="asb-9" name="asb-9"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan <br>Listing of Laboratories Utilized for Sample Analysis (Form G)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-9.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-10<a id="asb-10" name="asb-10"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Asbestos Management Plan <br>Summary of Laboratory Samples (Form H)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-10.dot','name','600','400','yes','yes','no','no')>doc</a> (51k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-11<a id="asb-11" name="asb-11"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan<br>Continuation Sheet (Form I)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-11.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-11.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-12<a id="asb-12" name="asb-12"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Asbestos Management Plan<br>Description of Chain of Command (Form J)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-12.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-12.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-13<a id="asb-13" name="asb-13"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan<br>Plan for Reinspection (Form K)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-13.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-13.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-14<a id="asb-14" name="asb-14"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Asbestos Management Plan<br>Plan for Operations and Maintenance Activities (Form L)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-14.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-14.dot','name','600','400','yes','yes','no','no')>doc</a> (34k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-15<a id="asb-15" name="asb-15"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan<br>Plan to Inform (Form M)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-15.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-16<a id="asb-16" name="asb-16"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Asbestos Management Plan <br>Evaluation of Resources (Form N)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-16.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-17<a id="asb-17" name="asb-17"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan<br>Previous/Current Asbestos Abatement Log<br>(Form O)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-17.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-17.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-18<a id="asb-18" name="asb-18"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Asbestos Management Plan<br>Major/Minor Fiber Release Episode Log (Form P)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-18.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-18.dot','name','600','400','yes','yes','no','no')>doc</a> (34k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-19<a id="asb-19" name="asb-19"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Management Plan<br>Statement of Ensurances (Form Q)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-19.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-19.dot','name','600','400','yes','yes','no','no')>doc</a> (40k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">ASB-26<a id="asb-26" name="asb-26"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Facility Inspection Worksheet - Asbestos</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-26.pdf','name','600','400','yes','yes','no','no')>pdf</a> (16k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-26.dot','name','600','400','yes','yes','no','no')>doc</a> (70k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">ASB-41<a id="asb-41" name="asb-41"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Notification of Asbestos Abatement</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-41.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/asb-41.dot','name','600','400','yes','yes','no','no')>doc</a> (69k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">BACT-44<a id="bact-44" name="bact-44"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Bacteriological Sample Submittal<br><i>(Updated November 28, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/bact-44.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/bact-44.dot','name','600','400','yes','yes','no','no')>doc</a> (84k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/bact-44instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions for Completing Sample Submittal Forms</a> (pdf 11k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/bact-44instr_1.doc','name','600','400','yes','yes','no','no')>Instructions for Completing Sample Submittal Forms</a> (doc 26k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">BACT-109<a id="bact-109" name="bact-109"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Bacterial or Viral Culture or Parasite Identification<br><i>(Updated April 22nd, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/bact-109.pdf','name','600','400','yes','yes','no','no')>BACT-109</a> (1494k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">BIR-1<a id="bir-1" name="bir-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Commission on Brain Injury Research<br>Qualified Research Institution<br>Request for Approval<br><i>(Updated August 2020)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/bir-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1462k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CB-2<a id="cb-2" name="cb-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Fatal/Serious Accident Report <br><i> (Updated July 11th, 2024) </i></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-2.pdf','name','600','400','yes','yes','no','no')>CB-2</a> (920k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CB-11<a id="cb-11" name="cb-11"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application For Certificate of Approval To Operate a Youth Camp<br><i>(Updated March 15th, 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-11.pdf','name','600','400','yes','yes','no','no')>CB-11</a> (1261k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://dohepay.nj.gov/epayment/PaymentServlet?mode=verify&EFTCODE=14090&linkSeq=1021&amount=0','name','600','400','yes','yes','no','no')>Click here to pay online</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CB-11A<a id="cb-11a" name="cb-11a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Youth Camp Supplemental Information Form<br><i>(Updated February 7th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-11a.pdf','name','600','400','yes','yes','no','no')>CB-11a</a> (1231k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://dohepay.nj.gov/epayment/PaymentServlet?mode=verify&EFTCODE=14090&linkSeq=1021&amount=0','name','600','400','yes','yes','no','no')>Click here to pay online</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CB-14<a id="cb-14" name="cb-14"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application For Certificate of Approval To Operate a Single Sport Youth Camp<br><i>(Updated March 15th, 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-14.pdf','name','600','400','yes','yes','no','no')>CB-14</a> (1265k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://dohepay.nj.gov/epayment/PaymentServlet?mode=verify&EFTCODE=14090&linkSeq=1021&amount=0','name','600','400','yes','yes','no','no')>Click here to pay online</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CB-14A<a id="cb-14a" name="cb-14a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Youth Camp Supplemental Information Form<br><i>(Updated February 7th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-14a.pdf','name','600','400','yes','yes','no','no')>CB-14a</a> (1236k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://dohepay.nj.gov/epayment/PaymentServlet?mode=verify&EFTCODE=14090&linkSeq=1021&amount=0','name','600','400','yes','yes','no','no')>Click here to pay online</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CB-15<a id="cb-15" name="cb-15"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Annual Accident Report Youth Camp Safety Act</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1601k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CB-17<a id="cb-17" name="cb-17"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Youth Camp Self-Inspection Report (for Youth Camp Operators)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-17.pdf','name','600','400','yes','yes','no','no')>pdf</a> (23k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-17.dot','name','600','400','yes','yes','no','no')>doc</a> (125k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CB-18<a id="cb-18" name="cb-18"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Youth Camp Safety Detailed Data Sheet (for Local Health Inspectors)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-18.pdf','name','600','400','yes','yes','no','no')>pdf</a> (69k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-18.dot','name','600','400','yes','yes','no','no')>doc</a> (224k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CB-19<a id="cb-19" name="cb-19"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Youth Camp Safety Detailed Data Sheet (for Youth Camp Operators)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-19.pdf','name','600','400','yes','yes','no','no')>pdf</a> (74k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-19.dot','name','600','400','yes','yes','no','no')>doc</a> (319k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CB-20<a id="cb-20" name="cb-20"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Certification for the Replacement of Main Drain Covers in Pool/Spa</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-20.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cb-20.dot','name','600','400','yes','yes','no','no')>doc</a> (55k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CCR-27<a id="ccr-27" name="ccr-27"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Donation Mail-In Record</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ccr-27.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ccr-27.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDC-2<a id="cdc-2" name="cdc-2"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Report of Rabies Postexposure Treatment</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cdc-2.PDF','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cdc-2.dot','name','600','400','yes','yes','no','no')>doc</a> (61k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="cdc 50.42a" name="cdc 50.42a"/><a href="https://www.cdc.gov/hiv/pdf/guidelines/cdc-hiv-adult-case-report-form-2023.pdf" target=_blank>CDC 50.42A</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Adult HIV Confidential Case Report Form<br><i>(Updated April 6th, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cdc50-42a.pdf','name','600','400','yes','yes','no','no')>CDC50-42A</a> (724k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="cdc 50.42b" name="cdc 50.42b"/><a href="https://www.cdc.gov/hiv/pdf/guidelines/cdc-hiv-pediatric-case-report-form-2023.pdf" target=_blank>CDC 50.42B</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Pediatric HIV Confidential Case Report Form<br><i>(Updated April 6th, 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cdc50-42b.pdf','name','600','400','yes','yes','no','no')>CDC50-42B</a> (1240k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="cdc-52.56" name="cdc-52.56"/><a href="http://www.cdc.gov/legionella/downloads/case-report-form.pdf" target=_blank>CDC-52.56</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Legionellosis Case Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="cdc-52.79" name="cdc-52.79"/><a href="https://www.cdc.gov/nationalsurveillance/pdfs/cdc5279-covis-vibriosis-508c.pdf" target=_blank>CDC-52.79</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Cholera And Other Vibrio Illness Surveillance Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="cdc-52.5" name="cdc-52.5"/><a href="https://www.cdc.gov/typhoid-fever/media/pdfs/2024/07/typhi-surveillance-form.pdf" target=_blank>CDC-52.5</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Typhoid And Paratyphoid Fever Surveillance Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="cdc-54.7" name="cdc-54.7"/><a href="http://www.cdc.gov/parasites/trichinellosis/resources/pdf/trichinellosis_case_report_form.pdf" target=_blank>CDC-54.7</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Trichinosis Surveillance Case Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDC-CNHGQ<a id="cdc-cnhgq" name="cdc-cnhgq"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Cyclosporiasis Case Report<br><i>(Updated May 2nd, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cdc-cnhgq.pdf','name','600','400','yes','yes','no','no')>CDC-CNHGQ</a> (1022k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDC-LCR<a id="cdc-lcr" name="cdc-lcr"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Listeria Case Report<br><i>(Updated September, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cdc-lcr.pdf','name','600','400','yes','yes','no','no')>pdf</a> (280k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDC-MIS<a id="cdc-mis" name="cdc-mis"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Multisystem Inflammatory Syndrome Associated with COVID-19: Case Report Form</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cdc-mis.pdf','name','600','400','yes','yes','no','no')>pdf</a> (957k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-1<a id="cds-1" name="cds-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">For Reporting Reportable Communicable Diseases</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-1.dot','name','600','400','yes','yes','no','no')>doc</a> (86k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-6<a id="cds-6" name="cds-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Amoebiasis Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> This form has been removed. </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-7<a id="cds-7" name="cds-7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Babesiosis Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-7.PDF','name','600','400','yes','yes','no','no')>pdf</a> (16k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-7.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-8<a id="cds-8" name="cds-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Creutzfeldt-Jacob Disease Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (24k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-8.dot','name','600','400','yes','yes','no','no')>doc</a> (49k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-9<a id="cds-9" name="cds-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Guillain-Barre Syndrome Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-9.dot','name','600','400','yes','yes','no','no')>doc</a> (49k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-10<a id="cds-10" name="cds-10"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Kawasaki Syndrome Disease Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-10.dot','name','600','400','yes','yes','no','no')>doc</a> (44k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-11<a id="cds-11" name="cds-11"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Patient Symptoms Line Listing (Respiratory Tract Infection)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-11.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-11.dot','name','600','400','yes','yes','no','no')>doc</a> (97k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-12<a id="cds-12" name="cds-12"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Patient Symptoms Line Listing (Gastrointestinal Infection)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-12.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-12.dot','name','600','400','yes','yes','no','no')>doc</a> (175k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-13<a id="cds-13" name="cds-13"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Food-Specific Attack Rate Worksheet</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-13.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-13.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-14<a id="cds-14" name="cds-14"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Lyme Disease Case Investigation <BR> (Updated August 17, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-14.pdf','name','600','400','yes','yes','no','no')>pdf</a> (262k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-14.docx','name','600','400','yes','yes','no','no')>doc</a> (55k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> Use PDF (NEW!) for electronic AND hand-written completion. Word version contains instructions. </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-15<a id="cds-15" name="cds-15"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Hemolytic Uremic Syndrome (Postdiarrheal) Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-15.dot','name','600','400','yes','yes','no','no')>doc</a> (42k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-16<a id="cds-16" name="cds-16"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Epidemiology Surveillance Record (Hospital-Based Laboratory)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-16.dot','name','600','400','yes','yes','no','no')>doc</a> (93k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-17<a id="cds-17" name="cds-17"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Hepatitis C Report <br><i>(Updated November 21st, 2024)</i></td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-17.pdf','name','600','400','yes','yes','no','no')>CDS-17</a> (407k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-17A<a id="cds-17a" name="cds-17a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Hepatitis C Investigation Letter (short)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-17a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-17a.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-18<a id="cds-18" name="cds-18"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Report of Known or Suspected Avian Chlamydiosis (Psittacosis)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-18.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-18.dot','name','600','400','yes','yes','no','no')>doc</a> (44k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-25<a id="cds-25" name="cds-25"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Avian Influenza Screening Information</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-25.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-25.dot','name','600','400','yes','yes','no','no')>doc</a> (66k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-26<a id="cds-26" name="cds-26"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Speakers Bureau Request<br><i>(Updated July 9th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-26.pdf','name','600','400','yes','yes','no','no')>CDS-26</a> (766k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-30<a id="cds-30" name="cds-30"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Outbreak Report for Long Term Care and Other Institutions</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-30.pdf','name','600','400','yes','yes','no','no')>pdf</a> (27k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-30.dot','name','600','400','yes','yes','no','no')>doc</a> (139k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-30instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 20k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-30instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 27k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-31<a id="cds-31" name="cds-31"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Out-of-State Animal Bite Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-31.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-31.dot','name','600','400','yes','yes','no','no')>doc</a> (40k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-32<a id="cds-32" name="cds-32"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Zoonotic Disease Incident Report<br><i>(Updated December 15th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-32.pdf','name','600','400','yes','yes','no','no')>CDS-32</a> (150k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-34<a id="cds-34" name="cds-34"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Scabies Case Line List: Residents</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-34.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-34.dot','name','600','400','yes','yes','no','no')>doc</a> (80k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-35<a id="cds-35" name="cds-35"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Scabies Case Line List: Staff</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-35.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-35.dot','name','600','400','yes','yes','no','no')>doc</a> (75k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-36<a id="cds-36" name="cds-36"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Investigation/Outbreak Intake Record</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-36.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-36.dot','name','600','400','yes','yes','no','no')>doc</a> (55k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-37<a id="cds-37" name="cds-37"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Hepatitis B Case Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-37.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-37.dot','name','600','400','yes','yes','no','no')>doc</a> (91k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CDS-38<a id="cds-38" name="cds-38"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Outbreak Report for Child Care, School and Camp Settings</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-38.pdf','name','600','400','yes','yes','no','no')>pdf</a> (24k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-38.dot','name','600','400','yes','yes','no','no')>doc</a> (122k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CDS-40<a id="cds-40" name="cds-40"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">STEC Surveillance Case Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-40.pdf','name','600','400','yes','yes','no','no')>pdf</a> (804k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cds-40.docx','name','600','400','yes','yes','no','no')>doc</a> (97k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CEHS-15<a id="cehs-15" name="cehs-15"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Care Center - DOH Subsequent Notification <br><i>(Updated April 2018)</i><p><a href="https://iehprogram.nj.gov/" target="_new"><b>Submit Online</b></a> (preferred method)</p></td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cehs-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (194k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CEHS-17<a id="cehs-17" name="cehs-17"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Statement of Education and Experience Requirements<br>Lead Inspector / Risk Assessor</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cehs-17.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cehs-17.dot','name','600','400','yes','yes','no','no')>doc</a> (43k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CEHS-18<a id="cehs-18" name="cehs-18"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Statement of Education and Experience Requirements<br>Supervisor for Housing and Public Buildings</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cehs-18.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cehs-18.dot','name','600','400','yes','yes','no','no')>doc</a> (43k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CEHS-19<a id="cehs-19" name="cehs-19"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Statement of Education and Experience Requirements<br>Supervisor for Commercial Buildings and Superstructures</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cehs-19.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cehs-19.dot','name','600','400','yes','yes','no','no')>doc</a> (42k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CEOH-1<a id="ceoh-1" name="ceoh-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Checklist for Public Recreational Bathing Facilities <i> (Updated Jan 17) </i></td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ceoh-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (160k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ceoh-1.dot','name','600','400','yes','yes','no','no')>doc</a> (104k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CEOH-2<a id="ceoh-2" name="ceoh-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Notification of Non-Friable Asbestos Work Activities</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ceoh-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (347k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CEOH-3<a id="ceoh-3" name="ceoh-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Notification of Non-Friable Asbestos Work Activities Related to Superstorm Sandy</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ceoh-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ceoh-3.dot','name','600','400','yes','yes','no','no')>doc</a> (60k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CEOH-4<a id="ceoh-4" name="ceoh-4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Contractor Information for Non-Friable Asbestos Work Activities<br>Exemption Request</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ceoh-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (869k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="ces-4" name="ces-4"/><a href="http://web.doh.state.nj.us/apps2/forms/ces4.aspx" target=_blank>CES-4</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Level A - Aggregate Data</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-4.PDF','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-4.dot','name','600','400','yes','yes','no','no')>doc</a> (51k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CES-12<a id="ces-12" name="ces-12"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Hematology/Oncology Physician Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-12.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-12.dot','name','600','400','yes','yes','no','no')>doc</a> (59k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CES-14<a id="ces-14" name="ces-14"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Radiation Therapy Facility Report Form</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-14.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-14.dot','name','600','400','yes','yes','no','no')>doc</a> (58k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CES-15<a id="ces-15" name="ces-15"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Ambulatory Surgery Center Report Form</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-15.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CES-17<a id="ces-17" name="ces-17"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Dentist Report Form</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-17.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-17.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CES-18<a id="ces-18" name="ces-18"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Laboratory Report Form</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-18.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-18.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CES-36<a id="ces-36" name="ces-36"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Body Art or Ear-Piercing Establishment Report of Infection or Injury<br> <br>For Use by Local Health Department Officials only<br> <br><i>(Previously EHS-36)<br>(Updated September 9th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-36.pdf','name','600','400','yes','yes','no','no')>CES-36</a> (387k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CES-40<a id="ces-40" name="ces-40"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Physician Report Form (Non-Hospital Source)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-40.PDF','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ces-40.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CFO-1<a id="cfo-1" name="cfo-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Cottage Food Operator Permit<br><i>(Updated October 6, 2021)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cfo-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (2154k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cfo-1instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (443k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2<a id="ch-2" name="ch-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Record</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2.dot','name','600','400','yes','yes','no','no')>doc</a> (142k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2A<a id="ch-2a" name="ch-2a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Infancy: 2-6 Weeks)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2a.dot','name','600','400','yes','yes','no','no')>doc</a> (72k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2B<a id="ch-2b" name="ch-2b"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Infancy: 2 Months)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2b.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2b.dot','name','600','400','yes','yes','no','no')>doc</a> (70k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2C<a id="ch-2c" name="ch-2c"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Infancy: 4 Months)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2c.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2c.dot','name','600','400','yes','yes','no','no')>doc</a> (66k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2D<a id="ch-2d" name="ch-2d"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Infancy: 6 Months)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2d.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2d.dot','name','600','400','yes','yes','no','no')>doc</a> (72k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2E<a id="ch-2e" name="ch-2e"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Infancy: 9 Months)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2e.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2e.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2F<a id="ch-2f" name="ch-2f"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Infancy: 12 Months)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2f.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2f.dot','name','600','400','yes','yes','no','no')>doc</a> (70k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2G<a id="ch-2g" name="ch-2g"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 15 Months)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2g.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2g.dot','name','600','400','yes','yes','no','no')>doc</a> (69k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2H<a id="ch-2h" name="ch-2h"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 18 Months)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2h.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2h.dot','name','600','400','yes','yes','no','no')>doc</a> (69k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2I<a id="ch-2i" name="ch-2i"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 2 Years)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2i.pdf','name','600','400','yes','yes','no','no')>pdf</a> (29k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2i.dot','name','600','400','yes','yes','no','no')>doc</a> (72k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2J<a id="ch-2j" name="ch-2j"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 3 Years)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2j.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2j.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2K<a id="ch-2k" name="ch-2k"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 4 Years)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2k.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2k.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2L<a id="ch-2l" name="ch-2l"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 5 Years)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2l.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2l.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2M<a id="ch-2m" name="ch-2m"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 6 Years)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2m.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2m.dot','name','600','400','yes','yes','no','no')>doc</a> (69k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2N<a id="ch-2n" name="ch-2n"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 7 Years)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2n.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2n.dot','name','600','400','yes','yes','no','no')>doc</a> (69k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2O<a id="ch-2o" name="ch-2o"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 8 Years)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2o.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2o.dot','name','600','400','yes','yes','no','no')>doc</a> (69k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2P<a id="ch-2p" name="ch-2p"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 9 Years)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2p.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2p.dot','name','600','400','yes','yes','no','no')>doc</a> (65k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2Q<a id="ch-2q" name="ch-2q"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 10-12 Yrs)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2q.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2q.dot','name','600','400','yes','yes','no','no')>doc</a> (72k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-2R<a id="ch-2r" name="ch-2r"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 13-15 Yrs)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2r.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2r.dot','name','600','400','yes','yes','no','no')>doc</a> (73k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-2S<a id="ch-2s" name="ch-2s"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Conference - Health Assessment (Childhood: 16-20 Yrs)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2s.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-2s.dot','name','600','400','yes','yes','no','no')>doc</a> (70k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-5<a id="ch-5" name="ch-5"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Child Health Conference Encounter Record</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (35k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-5.dot','name','600','400','yes','yes','no','no')>doc</a> (35k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-7<a id="ch-7" name="ch-7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Child Health Services Quarterly Summary Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (35k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-7.dot','name','600','400','yes','yes','no','no')>doc</a> (70k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-7instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 28k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-7instr.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 33k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-8<a id="ch-8" name="ch-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Patient Referral</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (38k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-8.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-14<a id="ch-14" name="ch-14"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Universal Child Health Record<br><i>(Contact Child & Adolescent Health Program at 609-292-5666 for more information.)<br><i>(Updated October 6, 2017)</i></td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-14.pdf','name','600','400','yes','yes','no','no')>pdf</a> (49k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-14.docx','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-14instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 34k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-14instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 28k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CH-15<a id="ch-15" name="ch-15"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Care Plan for Children with Special Health Needs</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (29k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-15.dot','name','600','400','yes','yes','no','no')>doc</a> (88k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-15instr.pdf','name','600','400','yes','yes','no','no')>Instruction</a> (pdf 24k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-15instr.doc','name','600','400','yes','yes','no','no')>Instruction</a> (doc 30k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CH-16<a id="ch-16" name="ch-16"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Hearing Screening Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (60k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ch-16.dot','name','600','400','yes','yes','no','no')>doc</a> (82k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CHEM-44<a id="chem-44" name="chem-44"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Organic and Inorganic Chemistry Sample Submittal</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/chem-44.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/chem-44.dot','name','600','400','yes','yes','no','no')>doc</a> (100k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/chem-44instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions for Completing Sample Submittal Forms</a> (pdf 11k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/chem-44instr_1.doc','name','600','400','yes','yes','no','no')>Instructions for Completing Sample Submittal Forms</a> (doc 26k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CL-3<a id="cl-3" name="cl-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for a Clinical Laboratory License<br>(Onsite Testing Only)<br><i>(Updated October 10, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (320k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-3.docx','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.state.nj.us/health/phel/documents/labworkforce.xls','name','600','400','yes','yes','no','no')>Laboratory Personnel Excel Spread Sheet</a> </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-3instr_2.pdf','name','600','400','yes','yes','no','no')>Instructions for Completing the Application for a Clinical Lab License<br><i>(Updated Oct. 10, 2017)</a> (pdf 41k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-3instr_2.docx','name','600','400','yes','yes','no','no')>Instructions for Completing the Application for a Clinical Lab License<br><i>(Updated Oct. 10, 2017)</a> (doc 57k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CL-8<a id="cl-8" name="cl-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Blood Bank Annual Statistics (Out of Hospital and Emergency Only Transfusion Facilities)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-8.dot','name','600','400','yes','yes','no','no')>doc</a> (34k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CL-8A<a id="cl-8a" name="cl-8a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Blood Bank Annual Statistics (Hospitals)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-8a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (38k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-8a.dot','name','600','400','yes','yes','no','no')>doc</a> (199k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CL-9<a id="cl-9" name="cl-9"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Disclosure of Ownership and Control Interest<br><i>(Updated October, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-9.PDF','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-9.dot','name','600','400','yes','yes','no','no')>doc</a> (56k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CL-13<a id="cl-13" name="cl-13"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Blood Bank Annual Statistics<br>(Hematopoietic Progenitor Cell Facilities)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-13.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-13.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CL-14<a id="cl-14" name="cl-14"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Blood Bank Annual Statistics<br>(Perioperative Autologous Blood Collection and Administration Facilities)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-14.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-14.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CL-16<a id="cl-16" name="cl-16"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for a Blood Bank License</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-16.PDF','name','600','400','yes','yes','no','no')>pdf</a> (37k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-16.dot','name','600','400','yes','yes','no','no')>doc</a> (246k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CL-17<a id="cl-17" name="cl-17"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Blood Bank Annual Statistics (Umbilical Cord Blood Facilities)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-17.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-17.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CL-18<a id="cl-18" name="cl-18"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for a Clinical Laboratory License <br>(Collection Station Only)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-18.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-18.dot','name','600','400','yes','yes','no','no')>doc</a> (43k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CL-21<a id="cl-21" name="cl-21"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Error/Accident Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-21.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-21.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CL-34<a id="cl-34" name="cl-34"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Laboratory Personnel Qualification Appraisal</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-34.PDF','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-34.dot','name','600','400','yes','yes','no','no')>doc</a> (103k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CL-40<a id="cl-40" name="cl-40"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Blood Bank Personnel Qualification Appraisal</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-40.pdf','name','600','400','yes','yes','no','no')>pdf</a> (65k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-40.dot','name','600','400','yes','yes','no','no')>doc</a> (79k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CL-44<a id="cl-44" name="cl-44"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Transfusion Reaction Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-44.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-44.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CL-50<a id="cl-50" name="cl-50"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Brokers and Reagent Manufactureres - Annual Statistical Data</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-50.pdf','name','600','400','yes','yes','no','no')>pdf</a> (50k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-50.dot','name','600','400','yes','yes','no','no')>doc</a> (59k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CL-51<a id="cl-51" name="cl-51"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Blood Centers - Annual Statistical Data</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-51.pdf','name','600','400','yes','yes','no','no')>pdf</a> (29k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-51.dot','name','600','400','yes','yes','no','no')>doc</a> (129k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CL-58<a id="cl-58" name="cl-58"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Blood Bank License Fee</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-58.PDF','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cl-58.dot','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CMP-1<a id="cmp-1" name="cmp-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Funding from Civil Monetary Penalties<br><i>(Updated May 29th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cmp-1.pdf','name','600','400','yes','yes','no','no')>CMP-1</a> (1089k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="cms-116" name="cms-116"/><a href="http://www.cms.hhs.gov/cmsforms/downloads/cms116.pdf" target=_blank>CMS-116</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Clinical Laboratory Improvement Amendments (CLIA) Application for Certification</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CN-1<a id="cn-1" name="cn-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Full Review Certificate of Need Application for Long Term Care Facilities: General Long Term Care Beds; Specialized Long Term Care Beds<br><i>(Last Updated January 31st, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-1.pdf','name','600','400','yes','yes','no','no')>CN-1</a> (2582k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CN-3<a id="cn-3" name="cn-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Certificate of Need for Hospital-Related Projects<br><i>(Last Updated January 31st, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-3.pdf','name','600','400','yes','yes','no','no')>CN-3</a> (1131k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CN-4<a id="cn-4" name="cn-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Certificate of Need for Designation as a Perinatal Facility<br><i>(Last Updated January 31st, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-4.pdf','name','600','400','yes','yes','no','no')>CN-4</a> (1037k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CN-6<a id="cn-6" name="cn-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Project Application for an Adult Day Health Services Facility<br>(Formerly HFEL-3)<br><i>(Last Updated January 31st, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-6.pdf','name','600','400','yes','yes','no','no')>CN-6</a> (219k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CN-7<a id="cn-7" name="cn-7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for New or Amended Acute Care Facility License<br><i>(Last Updated August 16th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-7.pdf','name','600','400','yes','yes','no','no')>CN-7</a> (1054k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.nj.gov/health/healthfacilities/documents/ac/fees.pdf','name','600','400','yes','yes','no','no')>Fees for Licensure and Inspection</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CN-8<a id="cn-8" name="cn-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility<br>(Formerly HFEL-4)<br><i>(Last Updated January 31st, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-8.pdf','name','600','400','yes','yes','no','no')>CN-8</a> (206k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CN-9<a id="cn-9" name="cn-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Health Care Facility Inquiry Regarding Health Care Professional (HFEL-9) (updated August 10,2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-9.docx','name','600','400','yes','yes','no','no')>doc</a> (23k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-9instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 38k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CN-10<a id="cn-10" name="cn-10"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Annual Report of Megavoltage Radiation Unit</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-10.dot','name','600','400','yes','yes','no','no')>doc</a> (60k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CN-11<a id="cn-11" name="cn-11"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership (Formerly HFEL-8)<br><i>(Updated May, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-11.pdf','name','600','400','yes','yes','no','no')>pdf</a> (28k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-11.dot','name','600','400','yes','yes','no','no')>doc</a> (127k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-11instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 15k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-11instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 31k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CN-19<a id="cn-19" name="cn-19"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Certificate of Need Application-Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a)<br><i>(Last Updated January 31st, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-19.pdf','name','600','400','yes','yes','no','no')>CN-19</a> (812k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CN-28<a id="cn-28" name="cn-28"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Waiver<br><i>(Last Updated January 31st, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/cn-28.pdf','name','600','400','yes','yes','no','no')>CN-28</a> (184k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> New fillable PDF form!<br>Word document no longer available. </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CT-11<a id="ct-11" name="ct-11"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Records Release Authorization</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-11.pdf','name','600','400','yes','yes','no','no')>pdf</a> (23k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-11.dot','name','600','400','yes','yes','no','no')>doc</a> (134k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CT-11A<a id="ct-11a" name="ct-11a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Records Release Authorization (spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-11a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (23k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-11a.doc','name','600','400','yes','yes','no','no')>doc</a> (21k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CT-14<a id="ct-14" name="ct-14"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HIV Consent Form (Serology)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-14.pdf','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-14.doc','name','600','400','yes','yes','no','no')>doc</a> (21k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CT-24<a id="ct-24" name="ct-24"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HIV Confidential Consent Form (Serology)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-24.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-24.doc','name','600','400','yes','yes','no','no')>doc</a> (21k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CT-24A<a id="ct-24a" name="ct-24a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HIV Confidential Consent Form (Serology) (spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-24a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-24a.doc','name','600','400','yes','yes','no','no')>doc</a> (24k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CT-28<a id="ct-28" name="ct-28"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HIV Consent (Rapid Testing) - Confidential and Anonymous Testing</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-28.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-28.doc','name','600','400','yes','yes','no','no')>doc</a> (24k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CT-28A<a id="ct-28a" name="ct-28a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HIV Consent (Rapid Testing) (Confidential and Anonymous) (spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-28a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-28a.dot','name','600','400','yes','yes','no','no')>doc</a> (24k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CT-28B<a id="ct-28b" name="ct-28b"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HIV Consent (Rapid Testing) (Confidential and Anonymous) (Creole)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-28b.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-28b.dot','name','600','400','yes','yes','no','no')>doc</a> (23k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CT-29<a id="ct-29" name="ct-29"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HIV Consent (Rapid Testing) - Confidential Testing Only</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-29.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-29.doc','name','600','400','yes','yes','no','no')>doc</a> (23k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">CT-29A<a id="ct-29a" name="ct-29a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HIV Consent (Rapid Testing) (Confidential Only) (spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-29a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-29a.pdf','name','600','400','yes','yes','no','no')>doc</a> (12k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">CT-29B<a id="ct-29b" name="ct-29b"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HIV Consent (Rapid Testing) (Confidential Only) (Creole)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-29b.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ct-29b.dot','name','600','400','yes','yes','no','no')>doc</a> (23k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">DHAS-8<a id="dhas-8" name="dhas-8"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Eligibility for the HIV Home Care Program</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (25k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-8.dot','name','600','400','yes','yes','no','no')>doc</a> (113k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-8instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 18k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-8instr.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 29k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">DHAS-9<a id="dhas-9" name="dhas-9"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Client Intake Record</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (53k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-9.doc','name','600','400','yes','yes','no','no')>doc</a> (68k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">DHAS-35<a id="dhas-35" name="dhas-35"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Title II Reports</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/forms/dhas-35.xls','name','600','400','yes','yes','no','no')>excel 1.51mb</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">DHAS-38<a id="dhas-38" name="dhas-38"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Certification by Pharmacist</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-38.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-38.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">DHAS-39<a id="dhas-39" name="dhas-39"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Health Insurance Information<br>Health Insurance Continuation Program (HICP)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-39.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-39.dot','name','600','400','yes','yes','no','no')>doc</a> (51k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">DHAS-43<a id="dhas-43" name="dhas-43"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Confidential Laboratory Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhas-43.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1316k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">DHAS-44<a id="dhas-44" name="dhas-44"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Adult HIV/AIDS Confidential Case Report<br>(See CDC 50.42A)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">DHAS-45<a id="dhas-45" name="dhas-45"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Pediatric HIV/AIDS Confidential Case Report<br>(See CDC 50.42B)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">DHSTS-27<a id="dhsts-27" name="dhsts-27"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Participation in the AIDs Drug Distribution Program (ADDP) (Previously DHAS-27)<br><i>(Posted February 15th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhsts-27.pdf','name','600','400','yes','yes','no','no')>DHSTS-27</a> (1197k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">DHSTS-27b<a id="dhsts-27b" name="dhsts-27b"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Addendum to the Application for Participation in the AIDs Drug Distribution Program (ADDP) <br><i>(Posted February 15th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhsts-27b.pdf','name','600','400','yes','yes','no','no')>DHSTS-27b</a> (1304k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">DHSTS-37<a id="dhsts-37" name="dhsts-37"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Certification by Licensed Healthcare Practitioner (Previously DHAS-37)<br><i>(Updated February 15th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dhsts-37.pdf','name','600','400','yes','yes','no','no')>DHSTS-37</a> (837k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">DPF-663<a id="dpf-663" name="dpf-663"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">State of New Jersey<br>Application for Employment<br><i>(Updated March 14th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/dpf-663.pdf','name','600','400','yes','yes','no','no')>DPF-663</a> (813k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-1<a id="ehs-1" name="ehs-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Reciprocal Lead Permit<br><i>(Updated February 12th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-1.pdf','name','600','400','yes','yes','no','no')>EHS-1</a> (674k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-2<a id="ehs-2" name="ehs-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Renewal Application for Lead Training Agency Certification</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-2.dot','name','600','400','yes','yes','no','no')>doc</a> (51k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-4<a id="ehs-4" name="ehs-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Initial Application for Asbestos Training Agency Certification</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-4.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-5<a id="ehs-5" name="ehs-5"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Renewal Application for Asbestos Training Agency Certification<br><i>(Updated March 21st, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-5.pdf','name','600','400','yes','yes','no','no')>EHS-5</a> (131k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-6<a id="ehs-6" name="ehs-6"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Reciprocal Asbestos Accreditation<br><i>(Updated April 26th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-6.pdf','name','600','400','yes','yes','no','no')>EHS-6</a> (248k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-10<a id="ehs-10" name="ehs-10"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Facility Inspection Worksheet - Lead</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-10.dot','name','600','400','yes','yes','no','no')>doc</a> (74k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-15<a id="ehs-15" name="ehs-15"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Approval as a NJ Asbestos Course Instructor</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-15.dot','name','600','400','yes','yes','no','no')>doc</a> (65k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-16<a id="ehs-16" name="ehs-16"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Approval as a NJ Lead Course Instructor/Training Manager</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (66k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-16.dot','name','600','400','yes','yes','no','no')>doc</a> (69k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-21<a id="ehs-21" name="ehs-21"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Lead Training Course Notification</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-21.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-21.dot','name','600','400','yes','yes','no','no')>doc</a> (40k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-22<a id="ehs-22" name="ehs-22"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Lead Permit Worker-Housing and Public Buildings<br><i>(Updated September 2nd, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-22.pdf','name','600','400','yes','yes','no','no')>EHS-22</a> (698k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-23<a id="ehs-23" name="ehs-23"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Lead Permit Supervisor, Housing and Public Buildings<br><i>(Updated August 2nd, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-23.pdf','name','600','400','yes','yes','no','no')>EHS-23</a> (587k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-24<a id="ehs-24" name="ehs-24"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Lead Permit Inspector/Risk Assessor<br><i>(Updated November 16th, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-24.pdf','name','600','400','yes','yes','no','no')>EHS-24</a> (781k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-25<a id="ehs-25" name="ehs-25"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Lead Permit Planner/Project Designer<BR><I>(Updated August 2nd, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-25.pdf','name','600','400','yes','yes','no','no')>EHS-25</a> (177k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-26<a id="ehs-26" name="ehs-26"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Lead Permit Worker, Commercial Buildings and Superstructure<BR><I>(Updated August 2nd, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-26.pdf','name','600','400','yes','yes','no','no')>EHS-26</a> (202k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-27<a id="ehs-27" name="ehs-27"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Lead Permit Supervisor, Commercial Buildings and Superstructures<br><i>(Updated August 2nd, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-27.pdf','name','600','400','yes','yes','no','no')>EHS-27</a> (221k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-28<a id="ehs-28" name="ehs-28"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Initial Application for Lead Training Agency Certification</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-28.pdf','name','600','400','yes','yes','no','no')>pdf</a> (64k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-28.dot','name','600','400','yes','yes','no','no')>doc</a> (77k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-29<a id="ehs-29" name="ehs-29"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Replacement of Lead Permit<br><i>(Updated August 26, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-29.pdf','name','600','400','yes','yes','no','no')>EHS-29</a> (142k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-34<a id="ehs-34" name="ehs-34"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Approval to Operate a Body Art Establishment (Permanent) For use by Local Health Department Officials only.</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-34.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-34.dot','name','600','400','yes','yes','no','no')>doc</a> (72k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-35<a id="ehs-35" name="ehs-35"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Approval to Operate a Body Art Establishment (Temporary) For use by Local Health Department Officials only.</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-35.pdf','name','600','400','yes','yes','no','no')>pdf</a> (16k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-35.dot','name','600','400','yes','yes','no','no')>doc</a> (60k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-37<a id="ehs-37" name="ehs-37"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Training Course Notification</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-37.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-37.dot','name','600','400','yes','yes','no','no')>doc</a> (39k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-38<a id="ehs-38" name="ehs-38"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Lead Training Course Proposal Checklist</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-38.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-38.dot','name','600','400','yes','yes','no','no')>doc</a> (91k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-39<a id="ehs-39" name="ehs-39"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Asbestos Training Course Proposal Checklist</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-39.pdf','name','600','400','yes','yes','no','no')>pdf</a> (23k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-39.dot','name','600','400','yes','yes','no','no')>doc</a> (76k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-40<a id="ehs-40" name="ehs-40"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Hands-on Assessment<br>Lead Worker - Housing and Public Buildings</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-40.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-40.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-41<a id="ehs-41" name="ehs-41"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Hands-On Assessment<br>Lead Worker-Commercial Buildings and Superstructures</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-41.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-41.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-42<a id="ehs-42" name="ehs-42"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Hands-On Assessment<br>Lead Inspector / Risk Assessor</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-42.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-42.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-43<a id="ehs-43" name="ehs-43"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Hands-On Assessment<br>Lead Supervisor - Housing and Public Buildings</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-43.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-43.dot','name','600','400','yes','yes','no','no')>doc</a> (80k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-44<a id="ehs-44" name="ehs-44"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Hands-On Assessment<br>Lead Supervisor - Commercial Buildings and Superstructures</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-44.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-44.dot','name','600','400','yes','yes','no','no')>doc</a> (93k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-45<a id="ehs-45" name="ehs-45"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Hands-On Assessment<br>Lead Planner / Project Designer</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-45.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-45.dot','name','600','400','yes','yes','no','no')>doc</a> (96k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EHS-46<a id="ehs-46" name="ehs-46"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Reciprocity<br>Verification of Lead Licensure Status with New York State<br><i>(Updated August 1st, 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-46.pdf','name','600','400','yes','yes','no','no')>EHS-46</a> (157k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EHS-47<a id="ehs-47" name="ehs-47"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Inspection Checklist For Body Art Facilities</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ehs-47.pdf','name','600','400','yes','yes','no','no')>EHS-47</a> (1251k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS-10<a id="ems-10" name="ems-10"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMT Verification Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-10.dot','name','600','400','yes','yes','no','no')>doc</a> (40k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS-16<a id="ems-16" name="ems-16"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Survey Report for Mobility Assistance Vehicles (Sample)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (779k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS-19<a id="ems-19" name="ems-19"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Survey Report for Ambulance (Basic Life Support) (Sample)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-19.pdf','name','600','400','yes','yes','no','no')>pdf</a> (968k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS-20<a id="ems-20" name="ems-20"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Survey Report for Ambulance (Advanced Life Support) (Non-Transport) (Sample)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-20.pdf','name','600','400','yes','yes','no','no')>pdf</a> (953k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS-21<a id="ems-21" name="ems-21"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-21.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1076k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS-25<a id="ems-25" name="ems-25"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Quarterly Report of Specialty Care Transport Units</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-25.pdf','name','600','400','yes','yes','no','no')>pdf</a> (33k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-25.dot','name','600','400','yes','yes','no','no')>doc</a> (81k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-25instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 22k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-25instr.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 44k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS-27<a id="ems-27" name="ems-27"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Quarterly Report for Air Medical Units</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-27.pdf','name','600','400','yes','yes','no','no')>pdf</a> (39k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-27.dot','name','600','400','yes','yes','no','no')>doc</a> (116k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS-28<a id="ems-28" name="ems-28"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Emergency Medical Technician<br>Continuing Education Documentation<br>(With NJ/PA Logos)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-28.pdf','name','600','400','yes','yes','no','no')>pdf</a> (21k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-28.dot','name','600','400','yes','yes','no','no')>doc</a> (60k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS-43<a id="ems-43" name="ems-43"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMT Course Schedule</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-43.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1318k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS-44<a id="ems-44" name="ems-44"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Accreditation - Emergency Medical Technician Education Program</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-44.pdf','name','600','400','yes','yes','no','no')>pdf</a> (68k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-44.dot','name','600','400','yes','yes','no','no')>doc</a> (99k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS-56<a id="ems-56" name="ems-56"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Certification as an Emergency Medical Technician-Basic Instructor</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-56.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-56.dot','name','600','400','yes','yes','no','no')>doc</a> (45k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS-61<a id="ems-61" name="ems-61"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Emergency Medical Technician Training Fund Final Reimbursement Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-61.pdf','name','600','400','yes','yes','no','no')>pdf</a> (756k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS-62<a id="ems-62" name="ems-62"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Emergency Medical Technician (EMT) Training Fund Certificate of Eligibility for EMT Education</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-62.pdf','name','600','400','yes','yes','no','no')>pdf</a> (762k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS-63<a id="ems-63" name="ems-63"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Form A / EMS First Responder<br /> NJ Protocol for Scene Investigations of Infant and Child Deaths</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-63.pdf','name','600','400','yes','yes','no','no')>pdf</a> (23k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems--63.dot','name','600','400','yes','yes','no','no')>doc</a> (109k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS-64<a id="ems-64" name="ems-64"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMT & Paramedic Clinician Reciprocity Application Verification of EMT & Paramedic Education and Licensure</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-64.pdf','name','600','400','yes','yes','no','no')>pdf</a> (894k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS-65<a id="ems-65" name="ems-65"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMT Training Fund Payment Voucher</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ems-65.pdf','name','600','400','yes','yes','no','no')>pdf</a> (87k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EP-5<a id="ep-5" name="ep-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">New Jersey Medical Reserve Corps User Enrollment Request</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ep-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ep-5.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-2<a id="f-2" name="f-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Registration of Drug or Medical Device Manufacturing or Wholesale Drug or Medical Device Business <br><i>(Updated October 17th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-2.pdf','name','600','400','yes','yes','no','no')>F-2</a> (1149k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-5<a id="f-5" name="f-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Bulk and Bottled Water Establishment Application<br><i>(Updated May 30th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-5.pdf','name','600','400','yes','yes','no','no')>F-5</a> (1226k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-8<a id="f-8" name="f-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Initial Application for License to Operate a Refrigerated Warehouse and/or Locker Plant</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-8.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-9<a id="f-9" name="f-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Initial Application for License to Operate a Non-Alcoholic Beverage Manufacturing Plant</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-9.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-12<a id="f-12" name="f-12"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Certificate of Free Sale (CFS)<br><i>(Updated September 15th, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-12.pdf','name','600','400','yes','yes','no','no')>F-12</a> (845k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/ceohs/documents/food-drug-safety/cfs_guidelines.pdf','name','600','400','yes','yes','no','no')>Guidelines for Requesting Certificates of Free Sale (Updated November, 2016)</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-13<a id="f-13" name="f-13"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Renewal or Discontinuation Application to Operate a Wholesale Drug or Medical Device Business<br><i>(Updated October 17th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-13.pdf','name','600','400','yes','yes','no','no')>F-13</a> (427k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-17<a id="f-17" name="f-17"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Permit to Handle Nitrous Oxide<br><i>(Updated June 23rd, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-17.pdf','name','600','400','yes','yes','no','no')>pdf</a> (231k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-19<a id="f-19" name="f-19"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Renewal Application to Operate a Refrigerated Warehouse-Locker Plant<br><i>(Updated April 26th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-19.pdf','name','600','400','yes','yes','no','no')>F-19</a> (167k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-26<a id="f-26" name="f-26"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Self-Inspection Checklist (Wholesale)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-26.pdf','name','600','400','yes','yes','no','no')>pdf</a> (23k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-26.doc','name','600','400','yes','yes','no','no')>doc</a> (86k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-27<a id="f-27" name="f-27"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Self-Inspection Checklist (Retail)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-27.pdf','name','600','400','yes','yes','no','no')>pdf</a> (21k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-27.doc','name','600','400','yes','yes','no','no')>doc</a> (74k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-29<a id="f-29" name="f-29"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Initial Application for License to Operate a Wholesale Food-Cosmetic Establishment</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-29.pdf','name','600','400','yes','yes','no','no')>pdf</a> (30k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-29.dot','name','600','400','yes','yes','no','no')>doc</a> (66k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-30<a id="f-30" name="f-30"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Satisfactory Placard</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-30.pdf','name','600','400','yes','yes','no','no')>pdf</a> (26k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-30.dot','name','600','400','yes','yes','no','no')>doc</a> (246k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.state.nj.us/health/forms/f-note.shtml','name','600','400','yes','yes','no','no')>Note</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-31<a id="f-31" name="f-31"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Unsatisfactory Placard</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-31.pdf','name','600','400','yes','yes','no','no')>pdf</a> (26k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-31.dot','name','600','400','yes','yes','no','no')>doc</a> (245k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.state.nj.us/health/forms/f-note.shtml','name','600','400','yes','yes','no','no')>Note</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-32<a id="f-32" name="f-32"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Conditionally Satisfactory Placard</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-32.pdf','name','600','400','yes','yes','no','no')>pdf</a> (26k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-32.dot','name','600','400','yes','yes','no','no')>doc</a> (247k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.state.nj.us./health/forms/f-note.shtml','name','600','400','yes','yes','no','no')>Note</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-33<a id="f-33" name="f-33"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Sanitary Inspection Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-33.pdf','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-33.dot','name','600','400','yes','yes','no','no')>doc</a> (253k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.state.nj.us/health/forms/f-note.shtml','name','600','400','yes','yes','no','no')>Note</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-35<a id="f-35" name="f-35"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Retail Food Inspection Report (Local Health Departments)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-35.pdf','name','600','400','yes','yes','no','no')>pdf</a> (33k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-35.dot','name','600','400','yes','yes','no','no')>doc</a> (112k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.nj.gov/health/forms/f-note.shtml','name','600','400','yes','yes','no','no')>Note</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-37<a id="f-37" name="f-37"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Risk-Based Inspection Report (Local Health Departments)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-37.pdf','name','600','400','yes','yes','no','no')>pdf</a> (27k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-37.dot','name','600','400','yes','yes','no','no')>doc</a> (115k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.nj.gov/health/forms/f-note.shtml','name','600','400','yes','yes','no','no')>Note</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-39<a id="f-39" name="f-39"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Renewal Application to Operate a Non-Alcoholic Beverage and/or Bottling Plant<br><i>(Updated April 26th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-39.pdf','name','600','400','yes','yes','no','no')>F-39</a> (173k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-41<a id="f-41" name="f-41"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Renewal Application to Operate a Wholesale Food/Cosmetic Establishment<br><i>(Updated June 5th, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-41.pdf','name','600','400','yes','yes','no','no')>F-41</a> (179k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> New fillable PDF form!<br>Word document no longer available. </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-42<a id="f-42" name="f-42"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Renewal Application for Certification to Sell Bottled Water or Bulk Water<br><i>(Replaced by revised F-5 form on June 16th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-48<a id="f-48" name="f-48"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Certification to Handle Oysters, Clams or Mussels<br><i>(Updated May 29th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-48.pdf','name','600','400','yes','yes','no','no')>F-48</a> (796k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">FHS-10<a id="fhs-10" name="fhs-10"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Individualized Family Service Plan (IFSP)<br><i>(Posted August 26, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-10.pdf','name','600','400','yes','yes','no','no')>FHS-10</a> (954k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">FHS-16<a id="fhs-16" name="fhs-16"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Initial Uniform Application for Services to Individuals 21 and Under with Developmental Disabilities</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (33k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-16.dot','name','600','400','yes','yes','no','no')>doc</a> (61k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">FHS-18<a id="fhs-18" name="fhs-18"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Formal Dispute Resolution Request<br><i>(Updated August 26, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-18.pdf','name','600','400','yes','yes','no','no')>FHS-18</a> (697k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">FHS-19<a id="fhs-19" name="fhs-19"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Withdrawal of Dispute Resolution Request (formerly titled "Withdrawal of Complaint")</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-19.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-19.dot','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">FHS-19A<a id="fhs-19a" name="fhs-19a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Withdrawal of Complaint (Spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-19a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-19a.dot','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">FHS-22<a id="fhs-22" name="fhs-22"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Technical Assistance</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-22.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-22.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">FHS-25<a id="fhs-25" name="fhs-25"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Family Cost Participation Application for Income Adjustment <br><i>(Posted August 26, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-25.pdf','name','600','400','yes','yes','no','no')>FHS-25</a> (110k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">FHS-26<a id="fhs-26" name="fhs-26"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Family Cost Participation Income Documentation<br><i>(Posted August 26, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-26.pdf','name','600','400','yes','yes','no','no')>FHS-26</a> (850k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">FHS-27<a id="fhs-27" name="fhs-27"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Family Cost Participation - Payment Options <br><i>(Posted August 26, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-27.pdf','name','600','400','yes','yes','no','no')>FHS-27</a> (282k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">FHS-29<a id="fhs-29" name="fhs-29"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Family Cost Participation Tables - SFY 2023 Hourly Co-Pay<br><i>(Posted August 26, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fhs-29.pdf','name','600','400','yes','yes','no','no')>FHS-29</a> (1712k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">F-L3<a id="f-l3" name="f-l3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Certificate of Free Sale Package (English) (including F-L3 and F-12 Forms)<br><i>(Updated September 15th, 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-l3-eng.pdf','name','600','400','yes','yes','no','no')>F-L3</a> (866k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/ceohs/documents/food-drug-safety/cfs_guidelines.pdf','name','600','400','yes','yes','no','no')>Guidelines for Requesting Certificates of Free Sale (Updated November, 2016)</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">F-L4<a id="f-l4" name="f-l4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Certificate of Free Sale Package (Spanish) (including F-L4 and F-12 Forms)<br><i>(Updated September 15th, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/f-l4-span.pdf','name','600','400','yes','yes','no','no')>F-L4</a> (866k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/ceohs/documents/food-drug-safety/cfs_guidelines.pdf','name','600','400','yes','yes','no','no')>Guidelines for Requesting Certificates of Free Sale (Updated November, 2016)</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">FM-7<a id="fm-7" name="fm-7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMPLOYEE IDENTIFICATION (BUILDING/PARKING) MULTIFORM</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fm-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1272k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">FS-91<a id="fs-91" name="fs-91"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Statement of Interest Earned from Advance Payments Deposited into an Interest Bearing Account<br><i>(Updated February 21, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/fs-91.pdf','name','600','400','yes','yes','no','no')>FS-91</a> (116k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">GRANTS<a id="grants" name="grants"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Grant Application Package - Construction Grant (FS-26)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/grants_construction.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/grants_construction.dot','name','600','400','yes','yes','no','no')>doc</a> (35k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HCQ-1<a id="hcq-1" name="hcq-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">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)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (25k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-1.dot','name','600','400','yes','yes','no','no')>doc</a> (91k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HCQ-2<a id="hcq-2" name="hcq-2"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">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)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-2.dot','name','600','400','yes','yes','no','no')>doc</a> (62k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HCQ-3<a id="hcq-3" name="hcq-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Daily Patient Care Staffing: Inpatient Units</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-3.dot','name','600','400','yes','yes','no','no')>doc</a> (54k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-3instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 13k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-3instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 24k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HCQ-3A<a id="hcq-3a" name="hcq-3a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Daily Patient Care Staffing - Inpatient (Spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-3a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-3a.dot','name','600','400','yes','yes','no','no')>doc</a> (58k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-3ainstr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 14k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-3ainstr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 26k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HCQ-4<a id="hcq-4" name="hcq-4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Daily Patient Care Staffing: Emergency Department</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-4.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-4instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 10k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-4instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 22k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HCQ-4A<a id="hcq-4a" name="hcq-4a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Daily Patient Care Staffing - Emergency Department (Spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-4a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-4a.dot','name','600','400','yes','yes','no','no')>doc</a> (32k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-4ainstr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 13k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-4ainstr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 25k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HCQ-5<a id="hcq-5" name="hcq-5"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Daily Patient Care Staffing: Post-Anesthesia Care Unit</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-5.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-5instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 10k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-5instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 22k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HCQ-5A<a id="hcq-5a" name="hcq-5a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Daily Patient Care Staffing - Post Anesthesia Care Unit (PACU) (Spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-5a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-5a.dot','name','600','400','yes','yes','no','no')>doc</a> (32k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-5ainstr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 13k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-5ainstr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 25k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HCQ-6<a id="hcq-6" name="hcq-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Daily Patient Care Staffing-Other Licensed Health Care Professionals: Hospital-Wide</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-6.dot','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-6instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 10k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-6instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 22k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HCQ-6A<a id="hcq-6a" name="hcq-6a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Daily Patient Care Staffing - Other Licensed Health Care Professionals, Hospital Wide (Spanish)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-6a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-6a.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-6ainstr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 11k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-6ainstr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 25k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HCQ-7<a id="hcq-7" name="hcq-7"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Cardiac Cathereterization Data Registry</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (81k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-7.dot','name','600','400','yes','yes','no','no')>doc</a> (252k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-7instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 1835k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HCQ-9<a id="hcq-9" name="hcq-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Open Heart Surgery Risk Stratification Project - Data Collection Form, Version 4.3<br><i>(Updated December, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (31k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-9.dot','name','600','400','yes','yes','no','no')>doc</a> (86k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcq-9instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions and Data Specifications <br><i>(Updated December, 2016)</a> (pdf 799k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HCQO-16<a id="hcqo-16" name="hcqo-16"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Non-Confidential Release</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcqo-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (21k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hcqo-16.dot','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HFEL-3<a id="hfel-3" name="hfel-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Project Application for an Adult Day Health Services Facility<br><i>(Changed to CN-6, May, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HFEL-4<a id="hfel-4" name="hfel-4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility<br><i>(Changed to CN-8, May, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="hfel-5" name="hfel-5"/><a href="https://dohlicensing.nj.gov/" target=_blank>HFEL-5</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment<br><i>(Updated April 8th, 2024)<br><a href=https://dohlicensing.nj.gov/></i><b>Submit Online</b></a></td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-5.pdf','name','600','400','yes','yes','no','no')>HFEL-5</a> (2104k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HFEL-6<a id="hfel-6" name="hfel-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Resident Care Staffing Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-6.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-6instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 12k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-6instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 23k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HFEL-7<a id="hfel-7" name="hfel-7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">New Jersey Universal Transfer Form</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (21k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-7.dot','name','600','400','yes','yes','no','no')>doc</a> (108k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-7instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 38k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hfel-7instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 66k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HFEL-8<a id="hfel-8" name="hfel-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership<br><i>(Changed to CN-11, May, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HIP-5<a id="hip-5" name="hip-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Laboratory PreScreening Worksheet</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hip-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (126k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hip-5.docx','name','600','400','yes','yes','no','no')>doc</a> (130k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HRC-1<a id="hrc-1" name="hrc-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Harm Reduction Center Registration Application<br><i>(Updated July 11th, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hrc-1.pdf','name','600','400','yes','yes','no','no')>HRC-1</a> (913k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">HRC-2<a id="hrc-2" name="hrc-2"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Harm Reduction Center Membership Card<br><i>(Posted June 19th, 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/hrc-2.pdf','name','600','400','yes','yes','no','no')>HRC-2</a> (745k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IEM-3<a id="iem-3" name="iem-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Specimens for Newborn Biochemical Screening</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/iem-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (86k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/iem-3.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IEM-15<a id="iem-15" name="iem-15"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Order form for Initial Newborn Screening Request (IEM-1) Forms</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/iem-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/iem-15.dot','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-3<a id="imm-3" name="imm-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Annual College Immunization Status Report<br><i>(Updated November 21st, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-3.pdf','name','600','400','yes','yes','no','no')>IMM-3</a> (1125k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-5<a id="imm-5" name="imm-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Varicella Case Report<br><i>(Updated May 13th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-5.pdf','name','600','400','yes','yes','no','no')>IMM-5</a> (331k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-6<a id="imm-6" name="imm-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Vaccines for Children Program<br>Vaccine Usage Report<br><i>(Updated April, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-6.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="imm-7" name="imm-7"/><a href="http://www.nj.gov/health/cd/imm_requirements/annualstatusrpt.shtml" target=_blank>IMM-7</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Annual Immunization Status Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-7_instr1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 244k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-8<a id="imm-8" name="imm-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Standard School/Child Care Center Immunization Record<br><b>(To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-9<a id="imm-9" name="imm-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Personal Immunization Record<br><b>(To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-10<a id="imm-10" name="imm-10"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Rubella Surveillance Worksheet</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (39k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-10.dot','name','600','400','yes','yes','no','no')>doc</a> (118k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-11<a id="imm-11" name="imm-11"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Measles Surveillance Worksheet</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-11.pdf','name','600','400','yes','yes','no','no')>pdf</a> (36k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-11.dot','name','600','400','yes','yes','no','no')>doc</a> (108k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-12<a id="imm-12" name="imm-12"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Retrospective Immunization Audit / Survey</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-12.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-12.dot','name','600','400','yes','yes','no','no')>doc</a> (111k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-13<a id="imm-13" name="imm-13"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Flu Vaccine Tracking Record</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-13.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-13.dot','name','600','400','yes','yes','no','no')>doc</a> (47k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-14<a id="imm-14" name="imm-14"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Immunization Audit Report Worksheet</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-14.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-14.dot','name','600','400','yes','yes','no','no')>doc</a> (94k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-14instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 175k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="imm-15" name="imm-15"/><a href="http://healthapps.state.nj.us/imm/school_audit_report.aspx" target=_blank>IMM-15</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Immunization Audit Report<br><i>(Updated October 20, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (185k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-15instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 39k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-15instr.pdf','name','600','400','yes','yes','no','no')>Immunization Reporting & Auditing Guidelines</a> (897k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-16<a id="imm-16" name="imm-16"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Provisional Admittance Student Tracking Record</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-16.dot','name','600','400','yes','yes','no','no')>doc</a> (41k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-18<a id="imm-18" name="imm-18"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Vaccines for Children (NJVFC) Program<br>New Provider Enrollment for Adult Site<br><i>(Updated July, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-18.pdf','name','600','400','yes','yes','no','no')>pdf</a> (32k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-18.dot','name','600','400','yes','yes','no','no')>doc</a> (133k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-20<a id="imm-20" name="imm-20"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Confidential Perinatal Hepatitis-B Case and Contact Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-20.pdf','name','600','400','yes','yes','no','no')>pdf</a> (21k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-20.dot','name','600','400','yes','yes','no','no')>doc</a> (122k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-20_instru.pdf','name','600','400','yes','yes','no','no')>Instructions for Completing the imm-20 Form</a> (pdf 13k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-20_instru.doc','name','600','400','yes','yes','no','no')>Instructions for Completing the imm-20 Form</a> (doc 24k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-21<a id="imm-21" name="imm-21"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Mumps Surveillance Worksheet</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-21.pdf','name','600','400','yes','yes','no','no')>pdf</a> (35k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-21.dot','name','600','400','yes','yes','no','no')>doc</a> (146k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-22<a id="imm-22" name="imm-22"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Tetanus Surveillance Worksheet</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-22.pdf','name','600','400','yes','yes','no','no')>pdf</a> (28k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-22.dot','name','600','400','yes','yes','no','no')>doc</a> (95k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-22_instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 23k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-22_instr.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 26k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-23<a id="imm-23" name="imm-23"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Meningococcal Disease Case Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-23.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-23.dot','name','600','400','yes','yes','no','no')>doc</a> (99k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-24<a id="imm-24" name="imm-24"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Pertussis Investigation Record</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-24.pdf','name','600','400','yes','yes','no','no')>pdf</a> (30k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-24.dot','name','600','400','yes','yes','no','no')>doc</a> (178k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-25<a id="imm-25" name="imm-25"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Vaccines for Children (VFC) Program<br>New Provider Agreement for Adult Sites<br><i>(Updated March 22, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-25.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-25.dot','name','600','400','yes','yes','no','no')>doc</a> (35k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-26<a id="imm-26" name="imm-26"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Vaccines for Children (NJVFC) Program<br>VFC New Provider Enrollment for Pediatric Site<br><i>(Updated July, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-26.pdf','name','600','400','yes','yes','no','no')>pdf</a> (32k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-26.dot','name','600','400','yes','yes','no','no')>doc</a> (137k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-28<a id="imm-28" name="imm-28"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Vaccines for Children (VFC) Program<br>Patient Eligibility Screening Record<br><i>(Updated July, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-28.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-28.dot','name','600','400','yes','yes','no','no')>doc</a> (56k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-28A<a id="imm-28a" name="imm-28a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">317 Program<br>Patient Eligibility Screening Record<br><i>(Updated July, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-28a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-28a.dot','name','600','400','yes','yes','no','no')>doc</a> (45k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-29<a id="imm-29" name="imm-29"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">New Jersey Immunization Information System (NJIIS)<br>Request for Change of User Security Authorization/<br> Request for Password Reset<br><i>(updated December 15th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-29.pdf','name','600','400','yes','yes','no','no')>IMM-29</a> (203k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-30<a id="imm-30" name="imm-30"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Vaccines for Children Program<br>Provider Disenrollment Request<br><i>(Updated April, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-30.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-30.dot','name','600','400','yes','yes','no','no')>doc</a> (52k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-31<a id="imm-31" name="imm-31"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Insured for Sure User Enrollment</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-31.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-31.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-32<a id="imm-32" name="imm-32"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NJIIS Consent to Participate (English)<br><i>(updated December 15th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-32.pdf','name','600','400','yes','yes','no','no')>IMM-32</a> (59k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-32A<a id="imm-32a" name="imm-32a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">NJIIS Consent to Participate (Spanish)<br><i>(updated December 15th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-32a.pdf','name','600','400','yes','yes','no','no')>IMM-32a</a> (60k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-34<a id="imm-34" name="imm-34"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Site Enrollment Request: </br>Early Hearing Detection and Intervention Program</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-34.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-34.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-35<a id="imm-35" name="imm-35"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">User Enrollment and Training Request: </br>Early Hearing Detection and Intervention Program</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-35.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-35.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-36<a id="imm-36" name="imm-36"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Vaccines for Children (VFC) Program<br>New Provider Agreement for Pediatric Sites<br><i>(Updated March 22, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-36.pdf','name','600','400','yes','yes','no','no')>pdf</a> (19k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-36.dot','name','600','400','yes','yes','no','no')>doc</a> (35k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-40<a id="imm-40" name="imm-40"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">New Jersey Immunization Information System (NJIIS)<br>Duplicate Record</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-40.pdf','name','600','400','yes','yes','no','no')>pdf</a> (130k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-40.docx','name','600','400','yes','yes','no','no')>doc</a> (22k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-41<a id="imm-41" name="imm-41"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NJIIS User Enrollment and Training Request<br><i>(updated December 15th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-41.pdf','name','600','400','yes','yes','no','no')>IMM-41</a> (76k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-42<a id="imm-42" name="imm-42"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Enrollment Request for New NJIIS Site<br><i>(updated December 15th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-42.pdf','name','600','400','yes','yes','no','no')>IMM-42</a> (88k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-42instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 13k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-43<a id="imm-43" name="imm-43"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">User Confidentiality Statement for Access to NJIIS/ User Confidentiality Agreement<br><i>(updated December 15th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-43.pdf','name','600','400','yes','yes','no','no')>IMM-43</a> (64k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-45<a id="imm-45" name="imm-45"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Change to NJIIS Immunization Record<br><i>(updated December 15th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-45.pdf','name','600','400','yes','yes','no','no')>IMM-45</a> (90k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-46<a id="imm-46" name="imm-46"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Copy of NJIIS Immunization Record<br><i>(updated December 15th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-46.pdf','name','600','400','yes','yes','no','no')>IMM-46</a> (59k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-47<a id="imm-47" name="imm-47"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Registrant Withdrawal from NJIIS<br><i>(updated December 15th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-47.pdf','name','600','400','yes','yes','no','no')>IMM-47</a> (57k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-48<a id="imm-48" name="imm-48"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Vaccines for Children Program<br>Request to Update Provider Information<br><i>(Updated April, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-48.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-48.dot','name','600','400','yes','yes','no','no')>doc</a> (36k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-53<a id="imm-53" name="imm-53"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Medical Exemption From Mandatory Immunization</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-53.pdf','name','600','400','yes','yes','no','no')>pdf</a> (653k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-54<a id="imm-54" name="imm-54"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Institutional Liaison Designation Form<br><i>(Posted October 5th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-54.pdf','name','600','400','yes','yes','no','no')>IMM-54</a> (809k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IMM-PKG-A<a id="imm-pkg-a" name="imm-pkg-a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Vaccines for Children (NJVFC) Program<br> New Provider Enrollment Package (Adult)<br><i>(Updated March 22, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-pkg-a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (42k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-pkg-a.dot','name','600','400','yes','yes','no','no')>doc</a> (146k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IMM-PKG-P<a id="imm-pkg-p" name="imm-pkg-p"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Vaccines for Children (NJVFC) Program<br>New Provider Enrollment Package (Pediatric)<br><i>(Updated March 22, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-pkg-p.pdf','name','600','400','yes','yes','no','no')>pdf</a> (43k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/imm-pkg-p.dot','name','600','400','yes','yes','no','no')>doc</a> (152k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IRB-1<a id="irb-1" name="irb-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Initial Review</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/irb-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (53k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/irb-1.dot','name','600','400','yes','yes','no','no')>doc</a> (178k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">IRB-2<a id="irb-2" name="irb-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application to Continue Human Subjects Research</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/irb-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (34k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/irb-2.dot','name','600','400','yes','yes','no','no')>doc</a> (186k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IRB-3<a id="irb-3" name="irb-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application to Modify Human Subjects Research</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/irb-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (17k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/irb-3.dot','name','600','400','yes','yes','no','no')>doc</a> (50k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/irb-3instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 31k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/irb-3instr.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 78k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">LAB-3<a id="lab-3" name="lab-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Microbiological Testing of Food Sample</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lab-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (16k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lab-3.dot','name','600','400','yes','yes','no','no')>doc</a> (36k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">LAB-05 CLINICAL<a id="lab-05 clinical" name="lab-05 clinical"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Testing of Suspected Pathogens of Public Health Significance and Chain of Custody<br><i>(Updated April 22nd, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lab-05clinical.pdf','name','600','400','yes','yes','no','no')>Lab-05Clinical</a> (1118k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">LAB-7<a id="lab-7" name="lab-7"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">HIV Test Requisition</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lab-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lab-7.dot','name','600','400','yes','yes','no','no')>doc</a> (8kk)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">LAB-10<a id="lab-10" name="lab-10"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Quantiferon-TB Gold<br>Test In-Tube Method (QFT-IT)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lab-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lab-10.dot','name','600','400','yes','yes','no','no')>doc</a> (49k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">LCS-4<a id="lcs-4" name="lcs-4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Communicable Disease Alert</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lcs-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lcs-4.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">LCS-5<a id="lcs-5" name="lcs-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for the Addition of Long-Term Care Beds<br><i>(Last Updated January 31st, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lcs-5.pdf','name','600','400','yes','yes','no','no')>LCS-5</a> (182k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">LCS-8<a id="lcs-8" name="lcs-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Facility Reporting Incident Data and Analysis Yield (FRIDAY)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lcs-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (36k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lcs-8.dot','name','600','400','yes','yes','no','no')>doc</a> (142k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">LCS-9<a id="lcs-9" name="lcs-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for a Long-Term Care Facility License<br><i>(Last Updated August 16th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lcs-9.pdf','name','600','400','yes','yes','no','no')>LCS-9</a> (258k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">LH-7<a id="lh-7" name="lh-7"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Registered Environmental Health Specialist Examination</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (60k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-7.dot','name','600','400','yes','yes','no','no')>doc</a> (206k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">LH-8<a id="lh-8" name="lh-8"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Health Officer Examination</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (52k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-8.dot','name','600','400','yes','yes','no','no')>doc</a> (179k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">LH-9<a id="lh-9" name="lh-9"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Uniform Shared Services Agreement (Template) for Local Public Health Services</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-9.dot','name','600','400','yes','yes','no','no')>doc</a> (59k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-9instr.pdf','name','600','400','yes','yes','no','no')>Guidelines for Uniform Shared Public Health Services Agreement</a> (pdf 20k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-9instr.doc','name','600','400','yes','yes','no','no')>Guidelines for Uniform Shared Public Health Services Agreement</a> (doc 26k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">LH-12<a id="lh-12" name="lh-12"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">New Jersey Local Health Report<br>Account Creation and Access Request<br><i>(Updated June 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-12.pdf','name','600','400','yes','yes','no','no')>pdf</a> (106k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-12instr_1.pdf','name','600','400','yes','yes','no','no')>Local Health Report Description</a> (pdf 95k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">LH-13<a id="lh-13" name="lh-13"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Red Book-Local Health Emergency Contact Directory<br>Account Creation and Access Request<br><i>(Updated June 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-13.pdf','name','600','400','yes','yes','no','no')>pdf</a> (92k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lh-13instr_1.pdf','name','600','400','yes','yes','no','no')>Red Book Directory Description</a> (pdf 182k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">LP-3<a id="lp-3" name="lp-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Report of Childhood Blood Lead Analysis by Independent Laboratory (for children 16 years of age and under)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lp-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/lp-3.dot','name','600','400','yes','yes','no','no')>doc</a> (32k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="ltc-2" name="ltc-2"/><a href="http://www.state.nj.us/humanservices/doas/home/forms.html" target=_blank>LTC-2</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Notification form Long-Term Care Facility of Admission or Termination of a Medicaid Beneficiary</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="ltc-4" name="ltc-4"/><a href="http://www.state.nj.us/humanservices/doas/home/forms.html" target=_blank>LTC-4</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Hospital Preadmission Screening Referral</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="ltc-19" name="ltc-19"/><a href="http://www.state.nj.us/humanservices/doas/home/forms.html" target=_blank>LTC-19</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Billing Assistance</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">M-3<a id="m-3" name="m-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for a Milk Plant or a Bulk Milk Hauler (BTU) Permit<br><i>(Updated June 16th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/m-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1035k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">M-5<a id="m-5" name="m-5"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">License to Manufacture Frozen Desserts Establishment Application<br><i>(Updated June 16th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/m-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (331k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">M-6<a id="m-6" name="m-6"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Renewal Application to Operate a Frozen Dessert Plant<br><i>(Replaced by revised M-5 form on June 16th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">M-7<a id="m-7" name="m-7"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Temporary Marketing Permit: <br>Frozen Desserts Manufacturing Plant</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/m-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/m-7.dot','name','600','400','yes','yes','no','no')>doc</a> (36k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">M-8<a id="m-8" name="m-8"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Renewal Application to Operate a Bulk Tank Unit/Milk Plant<br><i>(Replaced by revised M-3 form on June 16th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MAID-2<a id="maid-2" name="maid-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Mental Health Professional Compliance Form<br><i>(Updated October 8th, 2021)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/maid-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (922k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/advancedirective/maid','name','600','400','yes','yes','no','no')>Click here for additional information</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MAID-3<a id="maid-3" name="maid-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Attending Physician Follow Up Form<br><i>(Updated October 8th, 2021)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/maid-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (2048k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/advancedirective/maid','name','600','400','yes','yes','no','no')>Click here for additional information</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MAID-4<a id="maid-4" name="maid-4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Medication Dispensing Record<br><i>(Updated October 15th, 2021)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/maid-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (993k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/advancedirective/maid','name','600','400','yes','yes','no','no')>Click here for additional information</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MAID-5<a id="maid-5" name="maid-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Consulting Physician Compliance Form<br><i>(Updated October 8th, 2021)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/maid-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (927k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/advancedirective/maid','name','600','400','yes','yes','no','no')>Click here for additional information</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MAID-6<a id="maid-6" name="maid-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Medication To End My Life in a Humane and Dignified Manner<br><i>(Updated October 8th, 2021)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/maid-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (961k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/advancedirective/maid','name','600','400','yes','yes','no','no')>Click here for additional information</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MAID-7<a id="maid-7" name="maid-7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Attending Physician Compliance Form<br><i>(Updated October 8th, 2021)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/maid-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1047k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://nj.gov/health/advancedirective/maid','name','600','400','yes','yes','no','no')>Click here for additional information</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MH-A1<a id="mh-a1" name="mh-a1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (MH)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mh-a1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1620k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MMH-1<a id="mmh-1" name="mmh-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Chronic Disease Self-Management Program<br>"Take Control of Your Health"<br>Pre-Workshop Participant Survey (English)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-1.dot','name','600','400','yes','yes','no','no')>doc</a> (81k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MMH-1A<a id="mmh-1a" name="mmh-1a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Chronic Disease Self-Management Program<br>"Take Control of Your Health"<br>Pre-Workshop Participant Survey (Spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-1a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (51k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-1a.dot','name','600','400','yes','yes','no','no')>doc</a> (95k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MMH-2<a id="mmh-2" name="mmh-2"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Chronic Disease Self-Management Program<br>"Take Control of Your Health"<br>Post-Workshop Participant Survey (English)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-2.dot','name','600','400','yes','yes','no','no')>doc</a> (60k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MMH-2A<a id="mmh-2a" name="mmh-2a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Chronic Disease Self-Management Program<br>"Take Control of Your Health"<br>Post-Workshop Participant Survey (Spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-2a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (45k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-2a.dot','name','600','400','yes','yes','no','no')>doc</a> (71k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MMH-3<a id="mmh-3" name="mmh-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Diabetes Self-Management Program<br>"Take Control of Your Health"<br>Pre-Workshop Participant Survey (English)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (84k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-3.dot','name','600','400','yes','yes','no','no')>doc</a> (112k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MMH-3A<a id="mmh-3a" name="mmh-3a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Diabetes Self-Management Program<br>"Take Control of Your Health"<br>Pre-Workshop Participant Survey (Spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-3a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (28k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-3a.dot','name','600','400','yes','yes','no','no')>doc</a> (133k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MMH-4<a id="mmh-4" name="mmh-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Diabetes Self-Management Program<br>"Take Control of Your Health"<br>Post-Workshop Participant Survey (English)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (83k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-4.dot','name','600','400','yes','yes','no','no')>doc</a> (93k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MMH-4A<a id="mmh-4a" name="mmh-4a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Diabetes Self-Management Program<br>"Take Control of Your Health"<br>Post-Workshop Participant Survey (Spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-4a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (25k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-4a.dot','name','600','400','yes','yes','no','no')>doc</a> (108k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MMH-5<a id="mmh-5" name="mmh-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Faithful Families Eating Smart and Moving More<br>Healthy Food Policy</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (34k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-5.dot','name','600','400','yes','yes','no','no')>doc</a> (130k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MMH-6<a id="mmh-6" name="mmh-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Faithful Families Eating Smart and Moving More<br>Physical Activity Policy</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (34k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-6.dot','name','600','400','yes','yes','no','no')>doc</a> (130k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MMH-7<a id="mmh-7" name="mmh-7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Faithful Families Eating Smart and Moving More<br>Participant Entry Survey (English)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (40k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-7.dot','name','600','400','yes','yes','no','no')>doc</a> (192k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MMH-8<a id="mmh-8" name="mmh-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Faithful Families Eating Smart and Moving More<br>Participant Exit Survey (English)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (38k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-8.dot','name','600','400','yes','yes','no','no')>doc</a> (176k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MMH-9<a id="mmh-9" name="mmh-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Faithful Families Eating Smart and Moving More<br>Class or Program Evaluation (English)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (27k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmh-9.dot','name','600','400','yes','yes','no','no')>doc</a> (153k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">MMP-1<a id="mmp-1" name="mmp-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Law Enforcement Incident Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmp-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/mmp-1.dot','name','600','400','yes','yes','no','no')>doc</a> (34k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">MS-5<a id="ms-5" name="ms-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Continuation Sheet</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ms-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/ms-5.dot','name','600','400','yes','yes','no','no')>doc</a> (36k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NA-4<a id="na-4" name="na-4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">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<br><i>(Updated August 8th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/na-4.pdf','name','600','400','yes','yes','no','no')>NA-4</a> (189k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">NA-11<a id="na-11" name="na-11"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Addendum: CMA Training - List of Course Attendees<br><i>(Updated July 8th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/na-11.pdf','name','600','400','yes','yes','no','no')>NA-11</a> (226k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NH-1<a id="nh-1" name="nh-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Nursing Home Administrator License<br><i>(Updated September 1, 2021)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/nh-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (858k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">NH-5<a id="nh-5" name="nh-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Sponsor Application for Continuing Education Program Approval for Licensed Nursing Home Administrators<br><i>(Updated November 21st, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/nh-5.pdf','name','600','400','yes','yes','no','no')>NH-5</a> (732k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/nh-5instr_1.pdf','name','600','400','yes','yes','no','no')>Letter to Applicant</a> (pdf 21k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/nh-5instr_1.doc','name','600','400','yes','yes','no','no')>Letter to Applicant</a> (doc 742k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NH-6<a id="nh-6" name="nh-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Reciprocity<br>Verification of Out-of-State Licensure Status<br><i>(Updated September, 1, 2021)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/nh-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (737k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">NH-8<a id="nh-8" name="nh-8"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Approval of Administrative Intern Program<br><i>(Updated September 1, 2021)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/nh-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (751k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NH-9<a id="nh-9" name="nh-9"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Quarterly Progress Report for <br>Nursing Home Administrative Intern Program<br><i>(Updated September 1, 2021)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/nh-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (794k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">NH-10<a id="nh-10" name="nh-10"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Certification of Program Completion for Nursing Home Administrative Intern Program<br><i>(Updated September 1, 2021)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/nh-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (839k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OAS-F2<a id="oas-f2" name="oas-f2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">PDF Download Instructions</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oas-f2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (387k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OC-18<a id="oc-18" name="oc-18"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Meeting with Commissioner <br><i>(Updated February 21, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-18.pdf','name','600','400','yes','yes','no','no')>pdf</a> (23k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-18.dot','name','600','400','yes','yes','no','no')>doc</a> (223k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OC-19<a id="oc-19" name="oc-19"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Commissioner Event Attendance Request<br><i>(Updated June 5th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-19.pdf','name','600','400','yes','yes','no','no')>OC-19</a> (790k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OC-34<a id="oc-34" name="oc-34"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Government Records Request (OPRA) <br><i>(Updated September 19th, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-34.pdf','name','600','400','yes','yes','no','no')>OC-34</a> (1093k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OC-37<a id="oc-37" name="oc-37"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Institutional Approval of Intramural Research</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-37.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-37.dot','name','600','400','yes','yes','no','no')>doc</a> (36k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OC-40<a id="oc-40" name="oc-40"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">IRB Submission Checklist<br><i>(Updated March 16th, 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-40.pdf','name','600','400','yes','yes','no','no')>OC-40</a> (105k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OC-41<a id="oc-41" name="oc-41"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Agreement for Ethical Conduct of Human Subjects Research</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-41.pdf','name','600','400','yes','yes','no','no')>pdf</a> (31k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-41.dot','name','600','400','yes','yes','no','no')>doc</a> (101k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OC-45<a id="oc-45" name="oc-45"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Agreement for Ethical Conduct of Human Subjects Research (Federal Employees)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-45.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-45.dot','name','600','400','yes','yes','no','no')>doc</a> (48k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OC-51<a id="oc-51" name="oc-51"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Notice of Claim of Exemption of Tobacco Retail Establishment</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-51.pdf','name','600','400','yes','yes','no','no')>pdf</a> (35k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-51.dot','name','600','400','yes','yes','no','no')>doc</a> (85k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OC-53<a id="oc-53" name="oc-53"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Registration of Exempt Cigar Bar or Lounge</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-53.pdf','name','600','400','yes','yes','no','no')>pdf</a> (42k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-53.dot','name','600','400','yes','yes','no','no')>doc</a> (93k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OC-54<a id="oc-54" name="oc-54"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Renewal of Registration of Exempt Cigar Bar or Lounge</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-54.pdf','name','600','400','yes','yes','no','no')>pdf</a> (49k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-54.dot','name','600','400','yes','yes','no','no')>doc</a> (95k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OC-56<a id="oc-56" name="oc-56"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">NJ Smoke Free Air Act / Complaint<br><i>(Updated January 25,2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-56.pdf','name','600','400','yes','yes','no','no')>OC-56</a> (135k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OC-58<a id="oc-58" name="oc-58"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NJ Smoke Free Air Act / Anonymous Request for Investigation<br><i>(Updated January 25,2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-58.pdf','name','600','400','yes','yes','no','no')>OC-58</a> (89k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OC-59<a id="oc-59" name="oc-59"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Notice - Smoke Free Air Act <br><i>(Updated January 25,2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/oc-59.pdf','name','600','400','yes','yes','no','no')>OC-59</a> (259k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-1<a id="occ-1" name="occ-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Sharps Injury Log</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-1.pdf','name','600','400','yes','yes','no','no')>doc</a> (8k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-2<a id="occ-2" name="occ-2"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Exposure Incident Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-2.dot','name','600','400','yes','yes','no','no')>doc</a> (45k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-3<a id="occ-3" name="occ-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Source Individual Evaluation</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-3.dot','name','600','400','yes','yes','no','no')>doc</a> (38k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-4<a id="occ-4" name="occ-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Employee Exposure Determination</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-4.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-5<a id="occ-5" name="occ-5"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Employee Exposure Follow up Record</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-5.dot','name','600','400','yes','yes','no','no')>doc</a> (35k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-6<a id="occ-6" name="occ-6"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Hepatitis B Vaccine Immunization Record</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (7k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-6.dot','name','600','400','yes','yes','no','no')>doc</a> (32k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-8<a id="occ-8" name="occ-8"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Hepatitis B Declination Statement</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (7k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-8.dot','name','600','400','yes','yes','no','no')>doc</a> (24k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-9<a id="occ-9" name="occ-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Employee Education and Training Record</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-9.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="occ-12" name="occ-12"/><a href="https://www.state.nj.us/health/forms/occ-12.shtml" target=_blank>OCC-12</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Public Employees Occupational Safety and Health (PEOSH) Unit Request for On-Site Consultation</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-12.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-12.dot','name','600','400','yes','yes','no','no')>doc</a> (54k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.state.nj.us/health/forms/occ-12.shtml','name','600','400','yes','yes','no','no')>On-Line Form</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-15<a id="occ-15" name="occ-15"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Cleaning Schedule</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (7k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-15.dot','name','600','400','yes','yes','no','no')>doc</a> (26k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-16<a id="occ-16" name="occ-16"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">EMS Respiratory Protection Program Evaluation Questionnaire</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-16.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-16.dot','name','600','400','yes','yes','no','no')>doc</a> (41k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-22<a id="occ-22" name="occ-22"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Documentation of Respirator Training</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-22.pdf','name','600','400','yes','yes','no','no')>pdf</a> (7k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-22.dot','name','600','400','yes','yes','no','no')>doc</a> (25k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-23<a id="occ-23" name="occ-23"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">PEOSH Respirator Medical Evaluation Questionnaire</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-23.pdf','name','600','400','yes','yes','no','no')>pdf</a> (32k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-23.dot','name','600','400','yes','yes','no','no')>doc</a> (158k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-24<a id="occ-24" name="occ-24"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Firefighter Respirator Medical Evaluation Questionnaire</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-24.pdf','name','600','400','yes','yes','no','no')>pdf</a> (34k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-24.dot','name','600','400','yes','yes','no','no')>doc</a> (162k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-25<a id="occ-25" name="occ-25"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Documentation of Medical Evaluation for Respirator Use</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-25.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-25.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-30<a id="occ-30" name="occ-30"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Firefighter Respirator Fit Test Record</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-30.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-30.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-31<a id="occ-31" name="occ-31"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Occupational and Environmental Disease, Injury, or Poisoning Report by Health Care Provider<br><i>(Updated December 14, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-31.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-31.dot','name','600','400','yes','yes','no','no')>doc</a> (59k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-31instr_1.pdf','name','600','400','yes','yes','no','no')>Additional Information for Completing the OCC-31 Form <i>(New)</a> (pdf 16k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-31instr_1.doc','name','600','400','yes','yes','no','no')>Additional Information for Completing the OCC-31 Form <i>(New)</a> (doc 28k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-32<a id="occ-32" name="occ-32"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">EMS Responder Fit Test Record</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-32.pdf','name','600','400','yes','yes','no','no')>pdf</a> (7k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-32.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-33<a id="occ-33" name="occ-33"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Firefighter SCBA After Use/Daily Inspection Checklist</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-33.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-33.dot','name','600','400','yes','yes','no','no')>doc</a> (89k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-34<a id="occ-34" name="occ-34"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">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</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-34.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-34.dot','name','600','400','yes','yes','no','no')>doc</a> (48k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-37<a id="occ-37" name="occ-37"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">PEOSH Hazard Communication Standard, Documentation of Training</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-37.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-37.dot','name','600','400','yes','yes','no','no')>doc</a> (43k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-38<a id="occ-38" name="occ-38"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">PEOSH Hazard Communication Standard<br>Brief Self-Inspection Checklist</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-38.pdf','name','600','400','yes','yes','no','no')>pdf</a> (743k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://get.adobe.com/reader/','name','600','400','yes','yes','no','no')>NEW! fillable PDF form - use Adobe Reader (click to download Reader)</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-40<a id="occ-40" name="occ-40"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Worksheet for Hazardous Chemical List</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-40.pdf','name','600','400','yes','yes','no','no')>pdf</a> (109k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://get.adobe.com/reader/','name','600','400','yes','yes','no','no')>NEW! fillable PDF form - use Adobe Reader (click to download Reader)</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-41<a id="occ-41" name="occ-41"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Sample Letter for Requesting Safety Data Sheets (SDS's)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-41.pdf','name','600','400','yes','yes','no','no')>pdf</a> (2676k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://get.adobe.com/reader/','name','600','400','yes','yes','no','no')>NEW! fillable PDF form - use Adobe Reader (click to download Reader)</a> </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-46<a id="occ-46" name="occ-46"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Worker and Community Right to Know Act / Employer Outreach Survey</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-46.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-46.dot','name','600','400','yes','yes','no','no')>doc</a> (75k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OCC-54<a id="occ-54" name="occ-54"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Quarterly Report of RTK County Lead Agencies</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-54.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-54.dot','name','600','400','yes','yes','no','no')>doc</a> (47k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OCC-57<a id="occ-57" name="occ-57"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Public Employees Occupational Safety and Health (PEOSH) Unit Complaint</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-57.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/occ-57.dot','name','600','400','yes','yes','no','no')>doc</a> (53k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OPSP-1<a id="opsp-1" name="opsp-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">J-1 Visa Waiver / State Conrad 30 Program - Physician-Primary Care Survey, Initial/Biannual Service Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (254k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-1.docx','name','600','400','yes','yes','no','no')>doc</a> (22k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OPSP-2<a id="opsp-2" name="opsp-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">J-1 Visa Waiver / State Conrad 30 Program - Application for New Jersey</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (391k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2.docx','name','600','400','yes','yes','no','no')>doc</a> (32k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OPSP-2A<a id="opsp-2a" name="opsp-2a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Attachment A: Current Medical Staffing at Practice Site</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (187k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2a.docx','name','600','400','yes','yes','no','no')>doc</a> (18k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OPSP-2B<a id="opsp-2b" name="opsp-2b"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Attachment B: Health Care Resources Inventory</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2b.pdf','name','600','400','yes','yes','no','no')>pdf</a> (150k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2b.docx','name','600','400','yes','yes','no','no')>doc</a> (18k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OPSP-2C<a id="opsp-2c" name="opsp-2c"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Attachment C: Facility Current Sliding Fee Scale</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2c.pdf','name','600','400','yes','yes','no','no')>pdf</a> (156k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2c.docx','name','600','400','yes','yes','no','no')>doc</a> (16k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OPSP-2D<a id="opsp-2d" name="opsp-2d"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Attachment D: J-1 Physician Visa Waiver / State Conrad 30 Program - Statements</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2d.pdf','name','600','400','yes','yes','no','no')>pdf</a> (170k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-2d.docx','name','600','400','yes','yes','no','no')>doc</a> (17k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OPSP-3<a id="opsp-3" name="opsp-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Section 4-1, Health Facility's J-1 Visa Waiver / State Conrad 30 Program - Agreement</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (147k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-3.docx','name','600','400','yes','yes','no','no')>doc</a> (20k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OPSP-4<a id="opsp-4" name="opsp-4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Section 4-2, Physician J-1 Visa Waiver / State Conrad 30 Program - Affidavit and Agreement</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (181k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-4.docx','name','600','400','yes','yes','no','no')>doc</a> (22k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OPSP-5<a id="opsp-5" name="opsp-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Section 5, J-1 Visa Waiver Required Application Enclosures</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (175k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/opsp-5.docx','name','600','400','yes','yes','no','no')>doc</a> (17k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OTC-1<a id="otc-1" name="otc-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">American Cancer Society (ACS) Monthly Activity Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/otc-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (47k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/otc-1.dot','name','600','400','yes','yes','no','no')>doc</a> (262k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OTC-2<a id="otc-2" name="otc-2"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">GASP Monthly Activity Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/otc-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (41k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/otc-2.dot','name','600','400','yes','yes','no','no')>doc</a> (256k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">OTC-3<a id="otc-3" name="otc-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Mom's Quit Connection (MQC) Monthly Activity Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/otc-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (32k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/otc-3.dot','name','600','400','yes','yes','no','no')>doc</a> (221k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">OTC-4<a id="otc-4" name="otc-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Regional Grantee Monthly Activity Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/otc-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (36k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/otc-4.dot','name','600','400','yes','yes','no','no')>doc</a> (299k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">PG-1<a id="pg-1" name="pg-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Requisition for Printing and Graphic Design<br><i>(Updated December 5, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/pg-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (24k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/pg-1.dot','name','600','400','yes','yes','no','no')>doc</a> (58k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">PHSS-1<a id="phss-1" name="phss-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for Tanning Facilities Registration<br><i>(Updated August, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/phss-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/phss-1.dot','name','600','400','yes','yes','no','no')>doc</a> (78k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">PHSS-3<a id="phss-3" name="phss-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Tanning Facility Inspection Checklist<br><i>(Updated August, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/phss-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (26k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/phss-3.dot','name','600','400','yes','yes','no','no')>doc</a> (56k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">PHSS-4<a id="phss-4" name="phss-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/phss-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (2053k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/phss-4_instr1.pdf','name','600','400','yes','yes','no','no')>Instructions for Completing the PHSS-5 Payment Voucher</a> (pdf 9k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">PHSS-6<a id="phss-6" name="phss-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Confidential Medical Waste Exposure Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/phss-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/phss-6.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">PSP-1<a id="psp-1" name="psp-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Questionnaire to Assess Your Exposure Risk for Lead and Mercury (Quicksilver)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/psp-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1350k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">PV 6-93<a id="pv 6-93" name="pv 6-93"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Payment Voucher (Vendor Invoice)<br><i>(Updated May, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/pv6-93.pdf','name','600','400','yes','yes','no','no')>pdf</a> (32k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/pv6-93.dot','name','600','400','yes','yes','no','no')>doc</a> (74k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/pv6-93instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 8k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/pv6-93instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 20k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">RAD-4<a id="rad-4" name="rad-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Radioanalytical Services Sample Submittal</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/rad-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (25k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/rad-4.dot','name','600','400','yes','yes','no','no')>doc</a> (82k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/rad-4instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions for Completing Sample Submittal Forms</a> (pdf 12k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/rad-4instr_1.doc','name','600','400','yes','yes','no','no')>Instructions for Completing Sample Submittal Forms</a> (doc 32k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-1<a id="reg-1" name="reg-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Quarterly Report of Domestic Partnerships Registered<br><i>(Updated April 2, 2018)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-1_nodate.pdf','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-1_nodate.docx','name','600','400','yes','yes','no','no')>doc</a> (17k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-2<a id="reg-2" name="reg-2"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Delegation of Authority to Receive Certified Copy of Vital Record (Birth/Death)<br><i>(Updated December 26, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (72k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-2.docx','name','600','400','yes','yes','no','no')>doc</a> (18k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-3<a id="reg-3" name="reg-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Delegation of Authority to Receive Certified Copy <br>(Marriage/Civil Union)<br><i>(Updated December 26, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (73k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-3.docx','name','600','400','yes','yes','no','no')>doc</a> (18k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-5<a id="reg-5" name="reg-5"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Report of No Births, Marriages, Civil Unions, Domestic Partnerships or Fetal Deaths<br><i>(Updated April, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-5.PDF','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-5.dot','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-7E<a id="reg-7e" name="reg-7e"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for a Certified Copy of a "No Record of Marriage" Statement (English/Spanish)<br><i>(Updated November 23, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-7e.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1229k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-13<a id="reg-13" name="reg-13"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Certified Municipal Registrar Recertification Course Tracking Log<br><i>(Updated January, 2015)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-13.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-13.dot','name','600','400','yes','yes','no','no')>doc</a> (56k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-14<a id="reg-14" name="reg-14"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Disinterment-Transit Permit</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-14.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-14.dot','name','600','400','yes','yes','no','no')>doc</a> (44k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-15<a id="reg-15" name="reg-15"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application to Amend a New Jersey Vital Record / <br>Application for a Certified Copy of <i>Amended </i>Record<br><i>(Updated February 7, 2019)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-15.pdf','name','600','400','yes','yes','no','no')>pdf</a> (179k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-15.docx','name','600','400','yes','yes','no','no')>doc</a> (32k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-20<a id="reg-20" name="reg-20"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Authorization for Release of Cause of Death<br>Autorizaci贸n para la Emision de Causa de Muerte<br>(Combined English and espa帽ol)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-20.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-20.dot','name','600','400','yes','yes','no','no')>doc</a> (38k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-23X<a id="reg-23x" name="reg-23x"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Template for Electronic <b>Remarriage </b>License and Certificate<br>[Set up for Use on Traditional Laser Printers]<br><i>(New as of March 1, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-23x.dot','name','600','400','yes','yes','no','no')>doc</a> (47k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-23X_MFP<a id="reg-23x_mfp" name="reg-23x_mfp"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Template for Electronic <b>Remarriage</b> License and Certificate <br>[Set up for Use on Multifunction Peripheral (MFP) Devices]<br><i>(New as of March 1, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-23x_mfp.dot','name','600','400','yes','yes','no','no')>doc</a> (49k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-24X<a id="reg-24x" name="reg-24x"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Template for Electronic <b>Marriage </b>License and Certificate<br>[Set up for Use on Traditional Laser Printers]<br><i>(Updated March 1, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-24x.dot','name','600','400','yes','yes','no','no')>doc</a> (55k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-24X_MFP<a id="reg-24x_mfp" name="reg-24x_mfp"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Template for Electronic <b>Marriage </b>License and Certificate<br>[Set up for Use on Multifunction Peripheral (MFP) Devices]<br><i>(Updated March 1, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-24x_mfp.dot','name','600','400','yes','yes','no','no')>doc</a> (56k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-25<a id="reg-25" name="reg-25"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Notification of Marriage/Civil Union<br><i>(Updated November 1, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-25.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-25.dot','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-27A<a id="reg-27a" name="reg-27a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for a <u>Non-Genealogical</u> Certification or Certified Copy of a Vital Record <br>(English, fillable PDF with instructions)<br><i>(Updated April 30, 2019)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-27a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (391k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-27B<a id="reg-27b" name="reg-27b"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">APLICACI脫N PARA COPIAS CERTIFICADAS 脫 CERTIFICACIONES DE REGISTROS CIVILES <u> NO-ANCESTRO </u> <br> (fillable PDF, Espa帽ol con Instrucciones) <br><i>(Updated October 5, 2017)</i></td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-27b.pdf','name','600','400','yes','yes','no','no')>pdf</a> (301k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-28A<a id="reg-28a" name="reg-28a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for a <u>Genealogical</u> Certification or Certified Copy of a Vital Record <br> (fillable PDF, English, with instructions)<br><i>(Updated May 9, 2018)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-28a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (301k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-28B<a id="reg-28b" name="reg-28b"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">APLICACI脫N POR UNA COPIA CERTIFICADA 脫 CERTIFICACIONES DE UN REGISTRO CIVIL <u>ANCESTRO</u> <br> (fillable PDF, Espa帽ol con Instrucciones) <br><i>(Updated May 9, 2018)</i></td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-28b.pdf','name','600','400','yes','yes','no','no')>pdf</a> (325k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-33<a id="reg-33" name="reg-33"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Short Form Birth Certificate<br><i>(Replaces the REG-42D (1) and REG-42D (2))<br><i>(Updated February 7th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-33.pdf','name','600','400','yes','yes','no','no')>REG-33</a> (52k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-33b<a id="reg-33b" name="reg-33b"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Short Form Birth Certificate Version B<br> <i>(Replaces the REG-42D (1) and REG-42D (2))<br> (Updated February 7th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-33b.pdf','name','600','400','yes','yes','no','no')>REG-33b</a> (62k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-34<a id="reg-34" name="reg-34"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Amendment to New Jersey Vital Record of <br>Birth, Death, Fetal Death, Marriage, Remarriage, Civil Union, Domestic Partnership<br>(Replaces REG-35, REG-45, REG-56 and REG-60 Forms)<br><I>(Updated March 3, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-34.pdf','name','600','400','yes','yes','no','no')>pdf</a> (16k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-34.dot','name','600','400','yes','yes','no','no')>doc</a> (52k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-34instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions for Completing REG-34<br>Amendment to NJ Vital Record Form</a> (pdf 20k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-34instr_1.doc','name','600','400','yes','yes','no','no')>Instructions for Completing REG-34<br>Amendment to NJ Vital Record Form</a> (doc 28k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-35<a id="reg-35" name="reg-35"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Correcting a Birth Record for Child Whose Natural Parents Married After Its Birth<BR>(Replaced by revised REG-34 form on August 1, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-36<a id="reg-36" name="reg-36"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">New Records System for Birth Parents<br>Forms Package includes:<br> Form A, Contact Preference, and<br> Form B, Family History Information<br><i>(Updated January 1, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-36.pdf','name','600','400','yes','yes','no','no')>pdf</a> (450k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-36.dot','name','600','400','yes','yes','no','no')>doc</a> (340k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-36A<a id="reg-36a" name="reg-36a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">New Records System for Birth Parents<br>Form A, Contact Preference Form</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-36a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (27k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-36a.dot','name','600','400','yes','yes','no','no')>doc</a> (62k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-36B<a id="reg-36b" name="reg-36b"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">New Records System for Birth Parents<br>Form B, Family History Information Form</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-36b.pdf','name','600','400','yes','yes','no','no')>pdf</a> (44k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-36b.dot','name','600','400','yes','yes','no','no')>doc</a> (172k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-37A<a id="reg-37a" name="reg-37a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for <u>Non-Genealogical</u> Certification or Certified Copy of a Vital Record for Local Use <br>(fillable PDF, English, with instructions)<br><i>(Updated October 5, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-37ainstr_1.pdf','name','600','400','yes','yes','no','no')>NEW FORM!<br>Instructions for Local Registrars</a> (pdf 105k) </td></tr></table> <table><tr> <td> The forms are now ONLY available for download on the EDRS System. </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-37B<a id="reg-37b" name="reg-37b"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">APLICACI脫N PARA COPIAS CERTIFICADAS 脫 CERTIFICACIONES DE REGISTROS CIVILES <u>NO-ANCESTRO</u> for Local Use <br> (fillable PDF, Espa帽ol con Instrucciones) <br> <i>(Updated October 5, 2017)</i></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-37binstr_1.pdf','name','600','400','yes','yes','no','no')>NEW FORM!<br>Instructions for Local Registrars</a> (pdf 105k) </td></tr></table> <table><tr> <td> The forms are now ONLY available for download on the EDRS System. </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-38A<a id="reg-38a" name="reg-38a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for <u>Genealogical</u> Certification or Certified Copy of a Vital Record for Local Use <br>(fillable PDF, English, with instructions) <br><i>(Updated October 5, 2017)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-38ainstr_1.pdf','name','600','400','yes','yes','no','no')>NEW FORM!<br>Instructions for Local Registrars</a> (pdf 105k) </td></tr></table> <table><tr> <td> The forms are now ONLY available for download on the EDRS System. </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-38B<a id="reg-38b" name="reg-38b"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">APLICACI脫N POR UNA COPIA CERTIFICADA 脫 CERTIFICACIONES DE UN REGISTRO CIVIL <u>ANCESTRO</u> <br>(fillable PDF, Espa帽ol con Instrucciones) <br><i>(Updated October 5, 2017)</i></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-38binstr_1.pdf','name','600','400','yes','yes','no','no')>NEW FORM!<br>Instructions for Local Registrars</a> (pdf 105k) </td></tr></table> <table><tr> <td> The forms are now ONLY available for download on the EDRS System. </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-40<a id="reg-40" name="reg-40"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Attestation to Birth Certificate <br><i>(Updated November 21, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-40.pdf','name','600','400','yes','yes','no','no')>pdf</a> (39k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-40.dot','name','600','400','yes','yes','no','no')>doc</a> (48k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-41<a id="reg-41" name="reg-41"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for an Uncertified Copy of an Adopted Person's Original Birth Record</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-41.pdf','name','600','400','yes','yes','no','no')>pdf</a> (18k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-41.dot','name','600','400','yes','yes','no','no')>doc</a> (41k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-41instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 16k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-41instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 38k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-42F(1)<a id="reg-42f(1)" name="reg-42f(1)"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Marriage Template (long form with Parents' Names)<br>for use on REG-42A Certified Copy Paper<br><i>(Updated November, 2013)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-42f_1.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-42F(2)<a id="reg-42f(2)" name="reg-42f(2)"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Marriage Template (short form without Parents' Names)<br>for use on REG-42A Certified Copy Paper<br><i>(Updated November, 2013)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-42f_2.dot','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-42G<a id="reg-42g" name="reg-42g"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Death Template<br>for use on REG-42A Certified Copy Paper<br><i>(Updated April, 2014)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-42g.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-42H<a id="reg-42h" name="reg-42h"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Domestic Partnership Template<br>for use on REG-42A Certified Copy Paper<br><i>(Updated April, 2014)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-42h.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-42I (1)<a id="reg-42i (1)" name="reg-42i (1)"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Civil Union Template (without Parent Names)<br>for use on REG-42A Certified Copy Paper<br><i>(Updated April, 2014)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-42i_1.dot','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-42I(2)<a id="reg-42i(2)" name="reg-42i(2)"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Civil Union Template (with Parent Names)<br>for use on REG-42A Certified Copy Paper<br><i>(Updated April, 2014)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-42i_2.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-42J<a id="reg-42j" name="reg-42j"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Remarriage Template <br>for use on REG-42A Certified Copy Paper<br><i>(Updated October, 2013)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-42j.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-42K<a id="reg-42k" name="reg-42k"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Reaffirmation of Civil Union Template<br>for use on REG-42A Certified Copy Paper<br><i>(Updated April, 2014)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-42k.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-43<a id="reg-43" name="reg-43"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Transmittal of Court Order of Paternity<br><i>(Updated February 7, 2019)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-43.pdf','name','600','400','yes','yes','no','no')>pdf</a> (638k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> NEW! Fillable PDF Form </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-44<a id="reg-44" name="reg-44"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Report of Adoption<br>Registrar una Adopci贸n<br><i>(Updated February 7, 2019)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-44.pdf','name','600','400','yes','yes','no','no')>pdf</a> (74k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-44.docx','name','600','400','yes','yes','no','no')>doc</a> (23k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('http://www.nj.gov/health/vital/adoption.shtml','name','600','400','yes','yes','no','no')>English Instructions</a> </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('http://www.nj.gov/health/vital/adoption_sp.shtml','name','600','400','yes','yes','no','no')>espa帽ol Instrucciones</a> </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-45<a id="reg-45" name="reg-45"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Legal Name Change to Original Record of Birth, Marriage, Civil Union or Domestic Partnership<br>(Replaced by revised REG-34 form on August 1, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-56<a id="reg-56" name="reg-56"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Correcting a Birth Record for Out-of-Wedlock Child Whose Mother Married a Man Other Than the Natural Father<br>(Replaced by revised REG-34 form on August 1, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-60<a id="reg-60" name="reg-60"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Correcting the Birth Record of a Child Said to Have Been Born Out-of-Wedlock and Whose Natural Parents Have Not Married Each Other<br>(Replaced by revised REG-34 form on August 1, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-62<a id="reg-62" name="reg-62"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request to Purchase Certified Copy of Vital Records Forms<br><i>(Updated May 25, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-62.pdf','name','600','400','yes','yes','no','no')>REG-62</a> (192k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-64<a id="reg-64" name="reg-64"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Consent for Artificial Insemination<br><i>(Updated December, 2015)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-64.pdf','name','600','400','yes','yes','no','no')>pdf</a> (2724k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-66<a id="reg-66" name="reg-66"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Log of Voided Certified Copy Forms</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-66.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-66.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-68<a id="reg-68" name="reg-68"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request to Place on File a Certificate of Birth Resulting in Stillbirth<br>(Solicitud para Archivar un Registro de Partida de Nacimiento Resultando en Parto Muerto)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-68.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-68.dot','name','600','400','yes','yes','no','no')>doc</a> (36k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-68instr_1.pdf','name','600','400','yes','yes','no','no')>Guidelines (Guia), (English/espa帽ol) (REG-D34)</a> (pdf 31k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-68instr_1.doc','name','600','400','yes','yes','no','no')>Guidelines (Guia), (English/espa帽ol) (REG-D34)</a> (doc 37k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-69<a id="reg-69" name="reg-69"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Quarterly Report of Non-EDRS Burial Permits Issued<br><i>(Updated April 2, 2018)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-69_nodate.pdf','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-69_nodate.docx','name','600','400','yes','yes','no','no')>doc</a> (18k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-77<a id="reg-77" name="reg-77"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Application for License: Marriage, Remarriage, Civil Union, or Reaffirmation of Civil Union<br><i>(Updated April 8, 2019)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-77.docx','name','600','400','yes','yes','no','no')>pdf</a> (28k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-77.docx','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-77A<a id="reg-77a" name="reg-77a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for License: Marriage, Remarriage, Civil Union or Reaffirmation of Civil Union (Combined English and Spanish)<br>(Solicitud Para Licencia: Matrimonio, Rematrimonio, Union Civil, o Reafirmacion de Union Civil)<br><i>(Updated April 4, 2019)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-77a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (140k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-77a.docx','name','600','400','yes','yes','no','no')>doc</a> (35k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-D7<a id="reg-d7" name="reg-d7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Notice of Rights and Obligations of Domestic Partners</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (21k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d7.doc','name','600','400','yes','yes','no','no')>doc</a> (38k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-D7A<a id="reg-d7a" name="reg-d7a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Notice of Rights and Obligations of Domestic Partners (Spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d7a.PDF','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d7a.doc','name','600','400','yes','yes','no','no')>doc</a> (42k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-D30<a id="reg-d30" name="reg-d30"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">"Entering into a Marriage or Civil Union in New Jersey" Brochure<br><i>(Updated April 20th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d30.pdf','name','600','400','yes','yes','no','no')>REG-D30</a> (160k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-D30A<a id="reg-d30a" name="reg-d30a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">"Entering into a Marriage or Civil Union in New Jersey" Brochure (Spanish)<br><i>(Updated April 20th,2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d30a.pdf','name','600','400','yes','yes','no','no')>REG-D30a</a> (663k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-D30B<a id="reg-d30b" name="reg-d30b"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">"Entering into a Marriage or Civil Union in New Jersey" Brochure (Russian)<br><i>(Updated April 20th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d30b.pdf','name','600','400','yes','yes','no','no')>REG-D30b</a> (815k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-D30C<a id="reg-d30c" name="reg-d30c"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">"Entering into a Marriage or Civil Union in New Jersey" Brochure (Korean)<br><i>(Updated April 20th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d30c.pdf','name','600','400','yes','yes','no','no')>REG-D30c</a> (701k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-D33<a id="reg-d33" name="reg-d33"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">"Registering a Domestic Partnership in New Jersey" Brochure</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d33.pdf','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d33.doc','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-D33A<a id="reg-d33a" name="reg-d33a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">"Registering a Domestic Partnership in New Jersey" Brochure (espa帽ol)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d33a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (23k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d33a.doc','name','600','400','yes','yes','no','no')>doc</a> (47k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-D33B<a id="reg-d33b" name="reg-d33b"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">"Registering a Domestic Partnership in New Jersey" (Russian)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d33b.pdf','name','600','400','yes','yes','no','no')>pdf</a> (121k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d33b.doc','name','600','400','yes','yes','no','no')>doc</a> (41k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-D33C<a id="reg-d33c" name="reg-d33c"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">"Registering a Domestic Partnership in New Jersey" (Korean)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d33c.pdf','name','600','400','yes','yes','no','no')>pdf</a> (120k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d33c.doc','name','600','400','yes','yes','no','no')>doc</a> (49k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-D34<a id="reg-d34" name="reg-d34"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Guidelines for Requesting to Place on File a Certificate of Birth Resulting in Stillbirth (English/espa帽ol)<br><i>(Updated November 21, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d34.pdf','name','600','400','yes','yes','no','no')>pdf</a> (27k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-d34.doc','name','600','400','yes','yes','no','no')>doc</a> (44k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">REG-L2<a id="reg-l2" name="reg-l2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request Form and Attestation to Amend Sex Designation on a Birth Certificate for an Adult to Reflect Gender Identity</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-l2_1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (120k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">REG-L3<a id="reg-l3" name="reg-l3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Parent/Guardian Request Form and Attestation to Amend Sex Designation on a Birth Certificate for a Minor to Reflect Gender Identity</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/reg-l3_1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (168k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">SCH-0<a id="sch-0" name="sch-0"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Special Child Health Services Registration Form</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-0.pdf','name','600','400','yes','yes','no','no')>pdf</a> (184k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-0.dot','name','600','400','yes','yes','no','no')>doc</a> (205k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-0instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions and Legends</a> (pdf 167k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-0instr_1.dot','name','600','400','yes','yes','no','no')>Instructions and Legends</a> (doc 57k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">SCH-1<a id="sch-1" name="sch-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Autism Registration<br><i>(Updated November 16, 2016)</i><br>(This revised form is to be used in place of the SCH-0/SCH-1 combination.)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (30k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-1.dot','name','600','400','yes','yes','no','no')>doc</a> (158k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-1instr_1.doc','name','600','400','yes','yes','no','no')>Instructions<br>(Updated November 16, 2016)</a> (doc 52k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-1instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions<br>(Updated November 16, 2016)</a> (pdf 21k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">SCH-2<a id="sch-2" name="sch-2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Newborn Hearing Follow-Up Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (31k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-2.dot','name','600','400','yes','yes','no','no')>doc</a> (77k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-2instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 21k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-2instr.dot','name','600','400','yes','yes','no','no')>Instructions</a> (doc 32k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">SCH-3<a id="sch-3" name="sch-3"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Lost to Hearing Follow Up Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (25k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-3.dot','name','600','400','yes','yes','no','no')>doc</a> (63k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">SCH-6<a id="sch-6" name="sch-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Critical Congenital Heart Defects Screening Program<br>Aggregate Report</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-6.dot','name','600','400','yes','yes','no','no')>doc</a> (35k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">SCH-7<a id="sch-7" name="sch-7"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Notice of Availability of Supplemental Newborn Screening</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-7.pdf','name','600','400','yes','yes','no','no')>pdf</a> (225k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">SCH-7A<a id="sch-7a" name="sch-7a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Notice of Availability of Supplemental Newborn Screening (spanish)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-7a.pdf','name','600','400','yes','yes','no','no')>pdf</a> (222k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">SCH-13<a id="sch-13" name="sch-13"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Hearing Aids</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-13.pdf','name','600','400','yes','yes','no','no')>pdf</a> (29k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sch-13.dot','name','600','400','yes','yes','no','no')>doc</a> (56k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top"><a id="scr" name="scr"/><a href="http://www.state.nj.us/health/spinalcord/grantappforms.shtml" target=_blank>SCR</a></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Online Spinal Cord Research Grant Applications</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">SCR-1<a id="scr-1" name="scr-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Commission on Spinal Cord Research<br>Qualified Research Institution<br>Request for Approval<br><i>(Updated December 1st, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/scr-1.pdf','name','600','400','yes','yes','no','no')>SCR-1</a> (909k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">SLB-1<a id="slb-1" name="slb-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Sale, Lease, or Sale-Leaseback Agreement Form</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/slb-1.pdf','name','600','400','yes','yes','no','no')>SLB-1</a> (759k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">SRD-1<a id="srd-1" name="srd-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Viral Serology, Culture and Molecular Diagnostics<br><i>(Updated April 22nd, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/srd-1.pdf','name','600','400','yes','yes','no','no')>SRD-1</a> (1332k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">SRD-4<a id="srd-4" name="srd-4"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for Immunological/Isolation Services - Clinical Services Testing Unit</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/srd-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (25k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/srd-4.dot','name','600','400','yes','yes','no','no')>doc</a> (52k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">STD-1<a id="std-1" name="std-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Sexually Transmitted Disease Requisition Form<br><i>(Posted April 22nd, 2024)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/std-1.pdf','name','600','400','yes','yes','no','no')>STD-1</a> (1027k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">STD-11a<a id="std-11a" name="std-11a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Confidential Syphilis Case Report Form <br><i>(Updated September 25th, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/std-11a.pdf','name','600','400','yes','yes','no','no')>std-11a</a> (505k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">STD-11b<a id="std-11b" name="std-11b"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Confidential Gonorrhea Case Report Form <br><i>(Posted March 3rd, 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/std-11b.pdf','name','600','400','yes','yes','no','no')>std-11b</a> (864k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">STD-11c<a id="std-11c" name="std-11c"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Confidential Chlamydia Case Report Form <br><i>(Posted March 3rd, 2023)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/std-11c.pdf','name','600','400','yes','yes','no','no')>std-11c</a> (959k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">SUD-A1<a id="sud-a1" name="sud-a1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (SUD)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sud-a1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (1011k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">SUD-A2<a id="sud-a2" name="sud-a2"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">APPLICATION FOR NEW OR AMENDED RESIDENTIAL SUBSTANCE USE DISORDER TREATMENT FACILITY LICENSE N.J.A.C. 10:161A</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/sud-a2.doc','name','600','400','yes','yes','no','no')>doc</a> (242k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">TB-1<a id="tb-1" name="tb-1"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Quarterly Chest Clinic Activity Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-1.dot','name','600','400','yes','yes','no','no')>doc</a> (31k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">TB-3<a id="tb-3" name="tb-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Medication Request Order<br><i>(Updated March, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-3.dot','name','600','400','yes','yes','no','no')>doc</a> (96k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-3instr_1.pdf','name','600','400','yes','yes','no','no')>Medication Request Order Instructions<br>(Updated November, 2016)</a> (pdf 381k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">TB-4<a id="tb-4" name="tb-4"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">TB Field Referral</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-4.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-4.dot','name','600','400','yes','yes','no','no')>doc</a> (40k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">TB-5<a id="tb-5" name="tb-5"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Symptom Assessment for Pulmonary Tuberculosis (TB)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-5.pdf','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-5.dot','name','600','400','yes','yes','no','no')>doc</a> (29k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">TB-8<a id="tb-8" name="tb-8"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Religious Exemption - School TB Testing/Symptom Assessment Form</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-8.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">TB-9<a id="tb-9" name="tb-9"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Statement of Non-Infectiousness for Symptomatic Individual</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-9.dot','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">TB-10<a id="tb-10" name="tb-10"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Statement of Non-Infectiousness for Individual with TB Disease</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-10.dot','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">TB-41<a id="tb-41" name="tb-41"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Record of Contact Interview (Original + 1 Continuation Page)<br><i>(Updated December 15th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-41.pdf','name','600','400','yes','yes','no','no')>TB-41</a> (173k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-41instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 20k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">TB-41a<a id="tb-41a" name="tb-41a"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Record of Contact Interview (Original + 2 Continuation Pages)<br><i>(Updated December 15th, 2022)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-41a.pdf','name','600','400','yes','yes','no','no')>TB-41a</a> (798k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-41ainstr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 20k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">TB-41b<a id="tb-41b" name="tb-41b"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Record of Contact Interview (Original + 5 Continuation Pages)<br><i>(Updated December 15th, 2022)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-41b.pdf','name','600','400','yes','yes','no','no')>TB-41b</a> (1006k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-41binstr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 20k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">TB-43<a id="tb-43" name="tb-43"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Tuberculosis (TB) Testing Survey Results</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-43.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-43.dot','name','600','400','yes','yes','no','no')>doc</a> (98k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-43instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 9k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-43instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 22k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">TB-57<a id="tb-57" name="tb-57"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Annual Report of TB Testing in Schools</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-57.pdf','name','600','400','yes','yes','no','no')>pdf</a> (11k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-57.dot','name','600','400','yes','yes','no','no')>doc</a> (41k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-57instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 21k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-57instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 24k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">TB-70<a id="tb-70" name="tb-70"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">New Jersey Tuberculosis Case, Suspect and Status Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-70.pdf','name','600','400','yes','yes','no','no')>TB-70</a> (760k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tb-70instr.pdf','name','600','400','yes','yes','no','no')>Instructions for Completion of TB-70 Form</a> (577k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">TB QFT-1<a id="tb qft-1" name="tb qft-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Request for QuantiFERON-TB Gold / Mycobacteriology Culture<br><I>(Posted April 22nd, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/tbqft-1.pdf','name','600','400','yes','yes','no','no')>TB QFT-1</a> (1236k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"><a id="vaers" name="vaers"/><a href="https://vaers.hhs.gov/esub/step1" target=_blank>VAERS</a> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Vaccine Adverse Event Reporting System: Online</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">VIR-1<a id="vir-1" name="vir-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Requisition for Viral Serology</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vir-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (22k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vir-1.dot','name','600','400','yes','yes','no','no')>doc</a> (39k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> Complete per instructions on form </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">VIR-16<a id="vir-16" name="vir-16"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Request for Rabies Examination<br><i>(Updated April, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vir-16.PDF','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vir-16.dot','name','600','400','yes','yes','no','no')>doc</a> (57k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">VPH-1<a id="vph-1" name="vph-1"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Inspection Report of Kennels, Pet Shops, Shelters, and Pounds</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-1.pdf','name','600','400','yes','yes','no','no')>pdf</a> (16k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-1.dot','name','600','400','yes','yes','no','no')>doc</a> (66k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">VPH-2<a id="vph-2" name="vph-2"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Animal Rescue Organization Registration</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-2.pdf','name','600','400','yes','yes','no','no')>pdf</a> (236k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">VPH-3<a id="vph-3" name="vph-3"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">List of Licensed Kennels, Pet Shops, Shelters and Pounds</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-3.pdf','name','600','400','yes','yes','no','no')>pdf</a> (20k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-3.dot','name','600','400','yes','yes','no','no')>doc</a> (41k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-3instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 9k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-3instr.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 22k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">VPH-10<a id="vph-10" name="vph-10"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Monthly Dog License Report</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-10.pdf','name','600','400','yes','yes','no','no')>pdf</a> (13k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-10.dot','name','600','400','yes','yes','no','no')>doc</a> (39k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-10instr_1.doc','name','600','400','yes','yes','no','no')>Instructions<br>(Updated July 2016)</a> (doc 28k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-10instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions<br>(Updated July 2016)</a> (pdf 12k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">VPH-11<a id="vph-11" name="vph-11"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Notice of Animal Bite and Confinement</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-11.PDF','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-11.dot','name','600','400','yes','yes','no','no')>doc</a> (36k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-11instr_1.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 25k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-11instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 11k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">VPH-20<a id="vph-20" name="vph-20"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Certification of Veterinary Supervision of the Disease Control and Health Care Program at a Licensed Animal Facility<br><i>(Updated May, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-20.PDF','name','600','400','yes','yes','no','no')>pdf</a> (8k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-20.dot','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">VPH-23<a id="vph-23" name="vph-23"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Notice of Intent, State-Sponsored Municipal Rabies Vaccination Clinics<br><i>(Updated November 28, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-23.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-23.dot','name','600','400','yes','yes','no','no')>doc</a> (33k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-23instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions for State-Sponsored Municipal Rabies Vaccination Clinics<br>(Updated November, 2016)</a> (pdf 9k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-23instr_1.doc','name','600','400','yes','yes','no','no')>Instructions for State-Sponsored Municipal Rabies Vaccination Clinics<br>(Updated November, 2016)</a> (doc 23k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-23instr_2.pdf','name','600','400','yes','yes','no','no')>Policies and Guidelines for Animal Rabies Vaccination<br>(Updated November, 2016)</a> (pdf 11k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-23instr_2.doc','name','600','400','yes','yes','no','no')>Policies and Guidelines for Animal Rabies Vaccination<br>(Updated November, 2016)</a> (doc 26k) </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">VPH-25<a id="vph-25" name="vph-25"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">State-Sponsored Municipal Rabies Vaccination Clinic Report<br><i>(Updated December 7th, 2021)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-25.pdf','name','600','400','yes','yes','no','no')>pdf</a> (9k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-25.dot','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-25instr_1.pdf','name','600','400','yes','yes','no','no')>Instructions for State-Sponsored Municipal Rabies Vaccination Clinics<br>(Updated November, 2016)</a> (pdf 9k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-25instr_1.doc','name','600','400','yes','yes','no','no')>Instructions for State-Sponsored Municipal Rabies Vaccination Clinics<br>(Updated November, 2016)</a> (doc 23k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-25instr_2.pdf','name','600','400','yes','yes','no','no')>Policies and Guidelines for Animal Rabies Vaccination<br>(Updated November, 2016)</a> (pdf 11k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-25instr_2.doc','name','600','400','yes','yes','no','no')>Policies and Guidelines for Animal Rabies Vaccination<br>(Updated November, 2016)</a> (doc 26k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">VPH-26<a id="vph-26" name="vph-26"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Rabies Vaccination Certificate</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-26.pdf','name','600','400','yes','yes','no','no')>pdf</a> (12k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-26.dot','name','600','400','yes','yes','no','no')>doc</a> (36k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">VPH-28<a id="vph-28" name="vph-28"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Certificate of Exemption from Rabies Vaccination</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-28.pdf','name','600','400','yes','yes','no','no')>pdf</a> (21k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-28.dot','name','600','400','yes','yes','no','no')>doc</a> (38k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">VPH-32<a id="vph-32" name="vph-32"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for Animal Control Officer Certification</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-32.pdf','name','600','400','yes','yes','no','no')>pdf</a> (10k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-32.dot','name','600','400','yes','yes','no','no')>doc</a> (28k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">VPH-35<a id="vph-35" name="vph-35"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Rabies Testing Notification Form</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-35.pdf','name','600','400','yes','yes','no','no')>VPH-35</a> (728k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">VPH-36<a id="vph-36" name="vph-36"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">License Animal Facility or Animal Control Officer Complaints</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/vph-36.pdf','name','600','400','yes','yes','no','no')>pdf</a> (871k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">W-9<a id="w-9" name="w-9"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Vendor Questionnaire</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/W-9.pdf','name','600','400','yes','yes','no','no')>pdf</a> (37k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/W-9.dot','name','600','400','yes','yes','no','no')>doc</a> (70k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/W-9instr.pdf','name','600','400','yes','yes','no','no')>Instructions</a> (pdf 13k) </td></tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/W-9instr.doc','name','600','400','yes','yes','no','no')>Instructions</a> (doc 22k) </td></tr></table>   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">WIC-6<a id="wic-6" name="wic-6"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">WIC Vendor Selection Criteria <br><i>(Updated 11/8/2017)</i></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-6.pdf','name','600','400','yes','yes','no','no')>pdf</a> (98k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-6.docx','name','600','400','yes','yes','no','no')>doc</a> (27k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> New Fillable PDF! </td></tr></table>   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">WIC-8<a id="wic-8" name="wic-8"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">New Jersey Division of Taxation<br>Authorization for Release of Tax Return Information</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-8.pdf','name','600','400','yes','yes','no','no')>pdf</a> (21k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-8.dot','name','600','400','yes','yes','no','no')>doc</a> (742k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">WIC-11<a id="wic-11" name="wic-11"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Medical Documentation for WIC Formula and Approved WIC Foods for Infants, Children and Women<br><i>(Updated April, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-11.pdf','name','600','400','yes','yes','no','no')>pdf</a> (34k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-11.dot','name','600','400','yes','yes','no','no')>doc</a> (95k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">WIC-12<a id="wic-12" name="wic-12"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Designation of Infant Formula Manufacturer, Retailer, Wholesaler and Distributor</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-12.pdf','name','600','400','yes','yes','no','no')>pdf</a> (14k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-12.dot','name','600','400','yes','yes','no','no')>doc</a> (30k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">WIC-15A<a id="wic-15a" name="wic-15a"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Vendor Agreement (without signature page)<br>(September 1, 2022 - September 30, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-15a.pdf','name','600','400','yes','yes','no','no')>WIC-15a</a> (982k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">WIC-21<a id="wic-21" name="wic-21"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">Authorization AGreement for DirectDeposit (ACH) Credits</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-21.PDF','name','600','400','yes','yes','no','no')>pdf</a> (15k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-21.dot','name','600','400','yes','yes','no','no')>doc</a> (32k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">WIC-26<a id="wic-26" name="wic-26"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">WIC Commodity Price List Survey<br><i>(Updated October 31, 2017)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-26.pdf','name','600','400','yes','yes','no','no')>pdf</a> (384k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-26.docx','name','600','400','yes','yes','no','no')>doc</a> (79k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">WIC-32<a id="wic-32" name="wic-32"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">WIC Services<br> FMNP-SFMNP/CSFP COMPLAINT REPORT<br><i>(Updated July 2023)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-32.pdf','name','600','400','yes','yes','no','no')>WIC-32</a> (482k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">WIC-40<a id="wic-40" name="wic-40"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">Application for WIC Vendor Authorization<br><i>(Updated August 15th, 2024)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-40.pdf','name','600','400','yes','yes','no','no')>WIC-40</a> (1536k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> <tr style="background-color:#eeeeee; text-align:left; vertical-align:top"> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">WIC-41<a id="wic-41" name="wic-41"/> </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">NJ WIC Health Care Referral (Women)<br><i>(Updated April, 2016)</td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-41.pdf','name','600','400','yes','yes','no','no')>pdf</a> (43k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-41.dot','name','600','400','yes','yes','no','no')>doc</a> (95k)</td> </tr></table>   </td> <td style="background-color:#eeeeee; text-align:left; vertical-align:top">   </td> </tr> <tr> <td style="background-color:#ffffff; text-align:left; vertical-align:top">WIC-42<a id="wic-42" name="wic-42"/></td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">NJ WIC Health Care Referral (Infants and Children)<br><i>(Updated April, 2016)</td> <td style="background-color:#ffffff; text-align:left; vertical-align:top"> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-42.pdf','name','600','400','yes','yes','no','no')>pdf</a> (42k)</td> </tr></table> <table><tr> <td> <a href=javascript:NewWindow('https://www.nj.gov/health/forms/wic-42.dot','name','600','400','yes','yes','no','no')>doc</a> (86k)</td> </tr></table>   </td> <td style="background-color:#ffffff; text-align:left; vertical-align:top">   </td> </tr> </table> </td> </tr> </table> <script type="text/javascript"> //<![CDATA[ var Page_Validators = new Array(document.getElementById("ContentPlaceHolder1_RegularExpressionValidator1")); //]]> </script> <script type="text/javascript"> //<![CDATA[ var ContentPlaceHolder1_RegularExpressionValidator1 = document.all ? document.all["ContentPlaceHolder1_RegularExpressionValidator1"] : document.getElementById("ContentPlaceHolder1_RegularExpressionValidator1"); ContentPlaceHolder1_RegularExpressionValidator1.controltovalidate = "ContentPlaceHolder1_Keywords"; ContentPlaceHolder1_RegularExpressionValidator1.errormessage = "RegularExpressionValidator"; ContentPlaceHolder1_RegularExpressionValidator1.evaluationfunction = "RegularExpressionValidatorEvaluateIsValid"; ContentPlaceHolder1_RegularExpressionValidator1.validationexpression = "^([-@\',.& ]*[a-zA-Z]*[0-9]*)+$"; //]]> </script> <script type="text/javascript"> //<![CDATA[ var Page_ValidationActive = false; if (typeof(ValidatorOnLoad) == "function") { ValidatorOnLoad(); } function ValidatorOnSubmit() { if (Page_ValidationActive) { return ValidatorCommonOnSubmit(); } else { return true; } } //]]> </script> </form> </div> </div>  </div> </section> </div>  <div id="footer"> <div id="footerContent"> <a href="https://www.nj.gov/health/opra/index.html"><img src="/template-images/state/opranj_trans.png" alt="OPRA- Open Public RecordAct" width="75" height="56" border="0" align="left" id="opra"></a> <div id="eweb"> <ul class="footerMenu"> <li><a href="https://www.nj.gov/health/feedback.shtml" class="stateLinks">Contact Us</a></li> | <li><a href="https://www.nj.gov/nj/privacy.html" class="stateLinks">Privacy Notice</a></li> | <li><a href="https://www.nj.gov/nj/legal.html" class="stateLinks">Legal Statement</a></li> | <li><a href="https://www.nj.gov/nj/accessibility.html" class="stateLinks">Accessibility Statement</a></li> | <li><a href="https://www.nj.gov/"><img src="/template-images/state/footernj.png" alt="nj state elogo" border="0"></a></li> </ul> </div> <div id="state"> <span>Statewide: </span> <ul class="footerMenu"> <li><a href="https://www.nj.gov/nj/">NJ Home</a></li> | <li><a href="https://www.nj.gov/nj/gov/njgov/alphaserv.html">Services A to Z</a></li> | <li><a href="https://www.nj.gov/nj/deptserv.html">Departments/Agencies</a></li> | <li><a href="https://www.nj.gov/faqs/">FAQs</a></li> </ul> </div> <div id="dept"> <span>Department:</span> <ul class="footerMenu"> <li><a href="https://www.nj.gov/health/">NJDOH Home</a></li> | <li><a href="https://www.nj.gov/health/about/contact-us/">TTY Relay </a></li> | <li><a href="https://www.nj.gov/health/topics.shtml">Topic A to Z</a></li> | <li><a href="https://www.nj.gov/health/office-programs/"> Offices & Programs</a></li> | <li><a href="https://www.nj.gov/health/documents/notice_of_privacy_practices.pdf" target="_blank">Notice of Privacy Practices</a></li> </ul> </div> <div id="copyright"> Copyright © State of New Jersey, <script type="text/javascript" language="JavaScript"> </script> <noscript>1996-2013</noscript> <br> Department of Health<br> P. O. Box 360 <br>Trenton, NJ 08625-0360 <br>  </div> <script src="/js/webtrends.js" type="text/javascript"></script> <script type="text/javascript"> var _tag = new WebTrends(); _tag.dcsGetId(); </script> <script type="text/javascript"> _tag.dcsCollect(); </script> <noscript> <div><img alt="DCSIMG" id="DCSIMG" width="1" height="1" src="https://sdc.state.nj.us/dcstf1ino000008qls7rr9e92_5q1n/njs.gif?dcsuri=/nojavascript&WT.js=No&WT.tv=8.6.2"/></div> </noscript> </div>  </div>     <script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-P3V3PJ6');</script>  <script src="/js/modernizr.custom.28468.js" type="text/javascript"></script> <script async src="https://siteimproveanalytics.com/js/siteanalyze_6291948.js"></script>  <script type="text/javascript" src="/_Incapsula_Resource?SWJIYLWA=719d34d31c8e3a6e6fffd425f7e032f3&ns=1&cb=1421409665" async></script></body> </html>

CINXE.COM

Health Department Forms