Local Health Department Forms, Documents and Administrative Reference Main ContentAdministrative Reference Local Health Department Administrative Reference DocumentTraining MatrixLHD Training List Administrative Reference Download On-Site Sewer Permit Log (Environmental Health) Patient Consent Form - Infectious Disease Exposure (OSHA Bloodborne Pathogens) Post-exposure Incident Exposed Employee Consent Form (Environmental Health) Post-exposure Incident Exposed Individual Consent Form (Environmental Health) Receipts Log (Environmental Health) Receipts Management Internal Controls Policy - Sample (Financial Management) Record of Training on Exposure Guidelines and Requirements (OSHA Bloodborne Pathogens) Request For Refund (Environmental Health) Safety Planning Resource List (Abuse, Neglect, Violence) Training Matrix VS-8 Declaration Of Paternity Previous Relative ContentClinical Service GuideClinical Service Guide Forms and Teaching SheetsLocal Health Department Information Page Select a category All Clinic Health Environmental Health LHD Security Request LHD Forms and Docs DownloadLHD Document Types LHD Influenza Vaccination Supplemental PEF (English)Clinic Health LHD Influenza Vaccination Supplemental PEF (Spanish)Clinic Health CH-2A Vaccine Administration and Tuberculosis Testing RecordClinic Health CH-2A InstructionsClinic Health CH-3A Service RecordClinic Health CH-5 Registration, Authorizations, Certifications and Consents (English)Clinic Health CH-5 Registration, Authorizations, Certifications and Consents (Spanish)Clinic Health CH-5B Patient Registration and Income Determination (English)Clinic Health CH-5B Patient Registration and Income Determination (Spanish)Clinic Health CH-5 WIC - Registration, Consent and WIC Certification (English)Clinic Health CH-5 WIC - Registration, Consent and WIC Certification (Spanish)Clinic Health CH-12 Miscellaneous Screening and Lab TestsClinic Health CH-12 Form InstructionsClinic Health CH-23 Authorization for Release/Acquisition of Patient InformationClinic Health CH-23 Authorization for Release/Acquisition of Patient Information (Spanish)Clinic Health CH-23 InstructionsClinic Health CH-45 Patient Encounter Form (Excel)Clinic Health CH-45 Patient Encounter Form (PDF)Clinic Health LHD COVID-19 Vaccination Supplemental PEFClinic Health LHD COVID-19 Vaccination Supplemental PEF (Spanish)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 ReportClinic Health CH-48EO EPSDT Outreach Community ReportingClinic Health CH-NP Statement of No Proof of IncomeClinic Health DFS-200 Application for Permit/LicenseEnvironmental Health DFS-202 Application for a Permit to Operate a Food Service EstablishmentEnvironmental Health DFS-208 Food Establishment Inspection ReportEnvironmental Health DFS-210 Notice to Correct ViolationsEnvironmental Health DFS-212 Request for ConferenceEnvironmental Health Next Contact Information