Local Health Department Forms, Documents, and Administrative Reference

Administrative Reference

Administrative Reference
Download
Aging Report - Sample (Financial Management)
Appointment of Local Registrar and Deputy
Birth-Death Index Form HD
Collaborative Agreement for Advanced Practice Registered Nurse (Local Health Personnel)
Post-exposure Incident Exposed Employee Consent Form (Environmental Health)
Post-exposure Incident Exposed Individual Consent Form (Environmental Health)
Declination of Hepatitis B Vaccine (OSHA Bloodborne Pathogens)
Environmental Fee Revenue Procedures (Environmental Health)
Environmental Write-Off Form (Environmental Health)
Facility Lockdown Procedural Guidelines - Template (Preparing And Responding to Bioterrorism)
Family Planning Expanded Role Registered Nurse Collaboration of Agreement Sample (Local Health Personnel)
Food Safety Branch Vehicle Incident Report Reporting Form (Environmental Health)
Food Safety Branch Vehicle Incident Report Instructions (Environmental Health)
Human Trafficking Screening Questions (Abuse, Neglect, Violence)
Incident/Complaint Report Form (Incident Reports)
Laboratory Incident Form (Incident Reports)
Lead Warning Poison Notice (Environmental Health)
Local Health Department Employee Privacy and Security of Protected Health, Confidential and Sensative Information Agreement (Local Health Personnel)
Local Health Department Exposure Control Plan - Template (OSHA Bloodborne Pathogens)
Local Health Department Internal Controls Program Guidelines (Financial Management)

Core Clinical Services Guide
Local Health Department Information Page

Download	LHD Document Types
CH-12 Miscellaneous Screening and Lab Tests	Clinic Health
CH-12 Form Instructions	Clinic Health
CH-23 Authorization for Release/Acquisition of Patient Information	Clinic Health
CH-23 Instructions	Clinic Health
CH-23 Authorization for Release/Acquisition of Patient Information (Spanish)	Clinic Health
CH-2A Vaccine Administration and Tuberculosis Testing Record	Clinic Health
CH-2A Instructions	Clinic Health
CH-3A Service Record	Clinic Health
CH-45 Patient Encounter Form (PDF)	Clinic Health
CH-45 Patient Encounter Form (Excel)	Clinic Health
CH-47 Patient Services Supplemental Reporting Form (Word)	Clinic Health
CH-47 Patient Services Supplemental Reporting Form (PDF)	Clinic Health
CH-48 Community Health Services Report	Clinic Health
CH-48EO EPSDT Outreach Community Reporting	Clinic Health
CH-5 Registration, Authorizations, Certifications and Consents (English)	Clinic Health
CH-5B Patient Registration and Income Determination (English)	Clinic Health
CH-5B Patient Registration and Income Determination (Spanish)	Clinic Health
CH-5 Registration, Authorizations, Certifications and Consents (Spanish)	Clinic Health
CH-NP Statement of No Proof of Income	Clinic Health
DFS-200 Application for Permit/License	Environmental Health
DFS-202 Application for a Permit to Operate a Food Service Establishment	Environmental Health
DFS-208 Food Establishment Inspection Report	Environmental Health
DFS-210 Notice to Correct Violations	Environmental Health
DFS-212 Request for Conference	Environmental Health
DFS-213 Notice of Conference	Environmental Health
DFS-214 Enforcement Notice	Environmental Health
DFS-215 Application for Reinstatement	Environmental Health
DFS-222 Notice and Order of Quarantine/Voluntary Destruction	Environmental Health
DFS-232 Permit to Operate	Environmental Health
DFS-303 Application for Certification/Registration	Environmental Health

Local Health Department Forms, Documents, and Administrative Reference

Administrative Reference

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