Local Health Department Forms, Documents and Administrative Reference

​​Administrative Reference 

Local Health Department Administrative Reference Document

Training Matrix

LHD Training List

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All
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

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