Local Health Department Forms, Documents and Administrative Reference Main ContentAdministrative Reference Local Health Department Administrative Reference DocumentTraining MatrixLHD Training List Administrative Reference Documents 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) 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 Sensitive Information Agreement (Local Health Personnel) Local Health Department Exposure Control Plan - Template (OSHA Bloodborne Pathogens) Local Health Department Internal Controls Program Guidelines (Financial Management) Maternal And Child Health Coordination - Function Codes Medication Plan for Local Health Departments - Sample (Medical Records Management) Next 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