AIDS Drug Distribution Program (ADDP)
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| DHSTS-27 |
Application for Participation in the AIDs Drug Distribution Program (ADDP)
(Posted January 6th, 2025) |
|
|
| DHSTS-37 |
Certification by Licensed Healthcare Practitioner
(Updated January 6th, 2025) |
|
|
| DHSTS-47 |
Application for Participation in the Health Insurance Premium Payment Program (HIPP)
(Posted January 6th, 2025) |
|
|
Health Insurance Continuation Program
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| DHSTS-27 |
Application for Participation in the AIDs Drug Distribution Program (ADDP)
(Posted January 6th, 2025) |
|
|
| DHSTS-37 |
Certification by Licensed Healthcare Practitioner
(Updated January 6th, 2025) |
|
|
| DHSTS-47 |
Application for Participation in the Health Insurance Premium Payment Program (HIPP)
(Posted January 6th, 2025) |
|
|
Grant Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| DHAS-35 |
Title II Reports |
|
|
Case Reporting
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CDC 50.42A |
Adult HIV Confidential Case Report Form
(Updated April 6th, 2023) |
|
|
| CDC 50.42B |
Pediatric HIV Confidential Case Report Form
(Updated April 6th, 2023) |
|
|
| DHAS-43 |
Confidential Laboratory Report |
|
|
| DHAS-44 |
Adult HIV/AIDS Confidential Case Report
(See CDC 50.42A) |
|
|
| DHAS-45 |
Pediatric HIV/AIDS Confidential Case Report
(See CDC 50.42B) |
|
|
Tuberculosis Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| TB-1 |
Quarterly Chest Clinic Activity Report |
|
|
| TB-3 |
Medication Request Order
(Updated March, 2016) |
|
Medication Request Order Instructions
(Updated November, 2016) (pdf 381k)
|
| TB-5 |
Symptom Assessment for Pulmonary Tuberculosis (TB) |
|
|
| TB-8 |
Religious Exemption - School TB Testing/Symptom Assessment Form |
|
|
| TB-9 |
Statement of Non-Infectiousness for Symptomatic Individual |
|
|
| TB-10 |
Statement of Non-Infectiousness for Individual with TB Disease |
|
|
| TB-41 |
Record of Contact Interview (Original + 1 Continuation Page)
(Updated December 15th, 2022) |
|
|
| TB-41a |
Record of Contact Interview (Original + 2 Continuation Pages)
(Updated December 15th, 2022) |
|
Instructions (pdf 20k)
|
| TB-41b |
Record of Contact Interview (Original + 5 Continuation Pages)
(Updated December 15th, 2022) |
|
|
| TB-70 |
New Jersey Tuberculosis Case, Suspect and Status Report |
|
Instructions for Completion of TB-70 Form (577k)
|
Sexually Transmitted Diseases
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| STD-11a |
Confidential Syphilis Case Report Form
(Updated September 25th, 2023) |
|
|
| STD-11b |
Confidential Gonorrhea Case Report Form
(Posted March 3rd, 2023) |
|
|
| STD-11c |
Confidential Chlamydia Case Report Form
(Posted March 3rd, 2023) |
|
|
Other
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| HRC-1 |
Harm Reduction Center Registration Application
(Updated July 11th, 2023) |
|
|
| HRC-2 |
Harm Reduction Center Membership Card
(Posted June 19th, 2023) |
|
|
