Local Health Department Forms, Documents and Administrative Reference

Administrative Reference

Local Health Department Administrative Reference Document

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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Download	LHD Document Types
DFS-215 Application for Reinstatement	Environmental Health
DFS-222 Notice and Order of Quarantine/Voluntary Destruction	Environmental Health
DFS-232 Permit to Operate	Environmental Health
DFS-303 Application for Certification/Registration	Environmental Health
DFS-306 Application for a Permit/License	Environmental Health
DFS-308 Youth Camp Inspection Report	Environmental Health
DFS-309 Youth Camp Accident/Illness Report	Environmental Health
DFS-317 Application for a Permit	Environmental Health
DFS-319 Onsite Sewage Disposal Systems Application for Site Evaluation	Environmental Health
DFS-325 Request for Onsite Sewage Disposal System Variance	Environmental Health
DFS-326 Existing Sewage System and Owner's Affidavit	Environmental Health
DFS-327 Request for Service Record	Environmental Health
DFS-334 Alternative/Experimental Onsite Sewage Disposal System	Environmental Health
DFS-335 Business License Surety Bond	Environmental Health
DFS-336 Affidavit of Surety's Qualifications	Environmental Health
DFS-340 Application and Permit to Operate Day Camp Facilities	Environmental Health
DFS-345 Application for Site Evaluation and Permit to Operate a Disposal Site	Environmental Health
DFS-400 Tanning Facility Registration/Monitor	Environmental Health
DFS-405 Onsite Sewage Agency Referral Form	Environmental Health
Enviro Shelter Surveillance Form	Environmental Health
LHO-001 PSRS/BRIDGE Security Request	LHD Security Request
LHO-002 CMS PORTAL Security Request	LHD Security Request
LHO-003 EHMIS/PORTAL Security Request	LHD Security Request
LHO-004 CDP eReports Security Request	LHD Security Request
LHO-005 L-Drive Security Request (LHDs only)	LHD Security Request
LHO-006 Global Email Distribution Request Form	LHD Security Request
LHO-007 Splash-BI Tool Security Request	LHD Security Request
WIC-001 CDP WIC eReports Security Request	LHD Security Request

Local Health Department Forms, Documents and Administrative Reference

​Administrative Reference

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Administrative Reference