Local Health Department Forms, Documents and Administrative Reference Main ContentAdministrative Reference Local Health Department Administrative Reference Document 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 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-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 KY JENNEOS Screening FormClinic Health KY JYNNEOS Screening FormClinic 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 DFS-213 Notice of ConferenceEnvironmental Health DFS-214 Enforcement NoticeEnvironmental Health Next Contact Information