Local Health Department Forms, Documents and Administrative Reference

Administrative Reference

Administrative Reference Documents
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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)

Clinical Service Guide
Clinical Service Guide Forms and Teaching Sheets
Local Health Department Information Page

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LHD Forms and Docs
Download	LHD Document Types
2026–2027 Influenza Vaccine Administration Record
2026–2027 Influenza Vaccine Administration Record
LHD Influenza Vaccination Supplemental PEF (English)	Clinic Health
LHD Influenza Vaccination Supplemental PEF (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-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 Tests	Clinic Health
CH-12 Form Instructions	Clinic Health
CH-23 Authorization for Release/Acquisition of Patient Information	Clinic Health
CH-23 Authorization for Release/Acquisition of Patient Information (Spanish)	Clinic Health
CH-23 Instructions	Clinic Health
CH-45 Patient Encounter Form (Excel)	Clinic Health
CH-45 Patient Encounter Form (PDF)	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-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

Local Health Department Forms, Documents and Administrative Reference

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Administrative Reference