CDC Report Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CDC-2 |
Report of Rabies Postexposure Treatment |
|
|
| CDC-52.56 |
Legionellosis Case Report |
|
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| CDC-52.79 |
Cholera And Other Vibrio Illness Surveillance Report |
|
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| CDC-52.5 |
Typhoid And Paratyphoid Fever Surveillance Report |
|
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| CDC-54.7 |
Trichinosis Surveillance Case Report |
|
|
| CDC-CNHGQ |
Cyclosporiasis Case Report
(Updated May 2nd, 2022) |
|
|
| CDC-LCR |
Listeria Case Report
(Updated September, 2016) |
|
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Forms for Health Professionals
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| BACT-109 |
Request for Bacterial or Viral Culture or Parasite Identification
(Updated April 22nd, 2024) |
|
|
| CDC-MIS |
Multisystem Inflammatory Syndrome Associated with COVID-19: Case Report Form |
|
|
| CDS-1 |
For Reporting Reportable Communicable Diseases |
|
|
| CDS-6 |
Amoebiasis Report |
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This form has been removed.
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| CDS-7 |
Babesiosis Report |
|
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| CDS-8 |
Creutzfeldt-Jacob Disease Report |
|
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| CDS-9 |
Guillain-Barre Syndrome Report |
|
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| CDS-10 |
Kawasaki Syndrome Disease Report |
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| CDS-11 |
Patient Symptoms Line Listing (Respiratory Tract Infection) |
|
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| CDS-12 |
Patient Symptoms Line Listing (Gastrointestinal Infection) |
|
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| CDS-13 |
Food-Specific Attack Rate Worksheet |
|
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| CDS-14 |
Lyme Disease Case Investigation
(Updated August 17, 2017) |
|
Use PDF (NEW!) for electronic AND hand-written completion. Word version contains instructions.
|
| CDS-15 |
Hemolytic Uremic Syndrome (Postdiarrheal) Report |
|
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| CDS-16 |
Epidemiology Surveillance Record (Hospital-Based Laboratory) |
|
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| CDS-17 |
Hepatitis C Report
(Updated November 21st, 2024) |
|
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| CDS-17A |
Hepatitis C Investigation Letter (short) |
|
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| CDS-18 |
Report of Known or Suspected Avian Chlamydiosis (Psittacosis) |
|
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| CDS-25 |
Avian Influenza Screening Information |
|
|
| CDS-26 |
Speakers Bureau Request
(Updated July 9th, 2024) |
|
|
| CDS-30 |
Outbreak Report for Long Term Care and Other Institutions |
|
Instructions (pdf 20k)
Instructions (doc 27k)
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| CDS-31 |
Out-of-State Animal Bite Report |
|
|
| CDS-32 |
Zoonotic Disease Incident Report
(Updated December 15th, 2022) |
|
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| CDS-34 |
Scabies Case Line List: Residents |
|
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| CDS-35 |
Scabies Case Line List: Staff |
|
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| CDS-36 |
Investigation/Outbreak Intake Record |
|
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| CDS-37 |
Hepatitis B Case Report |
|
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| CDS-38 |
Outbreak Report for Child Care, School and Camp Settings |
|
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| CDS-40 |
STEC Surveillance Case Report |
|
|
| LAB-3 |
Request for Microbiological Testing of Food Sample |
|
|
| LAB-05 CLINICAL |
Request for Testing of Suspected Pathogens of Public Health Significance and Chain of Custody
(Updated April 22nd, 2024) |
|
|
| SRD-1 |
Request for Viral Serology, Culture and Molecular Diagnostics
(Updated April 22nd, 2024) |
|
|
| STD-1 |
Sexually Transmitted Disease Requisition Form
(Posted April 22nd, 2024) |
|
|
| TB QFT-1 |
Request for QuantiFERON-TB Gold / Mycobacteriology Culture
(Posted April 22nd, 2024) |
|
|
| VIR-16 |
Request for Rabies Examination
(Updated April, 2016) |
|
|
Vaccine Preventable Disease Program
Reporting Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| IMM-3 |
Annual College Immunization Status Report
(Updated November 21st, 2024) |
|
|
| IMM-5 |
Varicella Case Report
(Updated May 13th, 2024) |
|
|
| IMM-7 |
Annual Immunization Status Report |
|
|
| IMM-8 |
Standard School/Child Care Center Immunization Record
(To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.) |
|
|
| IMM-9 |
Personal Immunization Record
(To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.) |
|
|
| IMM-10 |
Rubella Surveillance Worksheet |
|
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| IMM-11 |
Measles Surveillance Worksheet |
|
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| IMM-12 |
Retrospective Immunization Audit / Survey |
|
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| IMM-13 |
Flu Vaccine Tracking Record |
|
|
| IMM-14 |
Immunization Audit Report Worksheet |
|
Instructions (pdf 175k)
|
| IMM-15 |
Immunization Audit Report
(Updated October 20, 2017) |
|
|
| IMM-16 |
Provisional Admittance Student Tracking Record |
|
|
| IMM-20 |
Confidential Perinatal Hepatitis-B Case and Contact Report |
|
|
| IMM-21 |
Mumps Surveillance Worksheet |
|
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| IMM-22 |
Tetanus Surveillance Worksheet |
|
|
| IMM-23 |
Meningococcal Disease Case Report |
|
|
| IMM-24 |
Pertussis Investigation Record |
|
|
| IMM-48 |
Vaccines for Children Program
Request to Update Provider Information
(Updated April, 2016) |
|
|
| IMM-53 |
Request for Medical Exemption From Mandatory Immunization |
|
|
| IMM-54 |
Institutional Liaison Designation Form
(Posted October 5th, 2022) |
|
|
| VAERS |
Vaccine Adverse Event Reporting System: Online |
|
|
NJ Immunization Information System
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| IMM-6 |
Vaccines for Children Program
Vaccine Usage Report
(Updated April, 2016) |
|
|
| IMM-18 |
Vaccines for Children (NJVFC) Program
New Provider Enrollment for Adult Site
(Updated July, 2016) |
|
|
| IMM-25 |
Vaccines for Children (VFC) Program
New Provider Agreement for Adult Sites
(Updated March 22, 2017) |
|
|
| IMM-26 |
Vaccines for Children (NJVFC) Program
VFC New Provider Enrollment for Pediatric Site
(Updated July, 2016) |
|
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| IMM-28 |
Vaccines for Children (VFC) Program
Patient Eligibility Screening Record
(Updated July, 2016) |
|
|
| IMM-28A |
317 Program
Patient Eligibility Screening Record
(Updated July, 2016) |
|
|
| IMM-29 |
New Jersey Immunization Information System (NJIIS)
Request for Change of User Security Authorization/
Request for Password Reset
(updated December 15th, 2022) |
|
|
| IMM-30 |
Vaccines for Children Program
Provider Disenrollment Request
(Updated April, 2016) |
|
|
| IMM-32 |
NJIIS Consent to Participate (English)
(updated December 15th, 2022) |
|
|
| IMM-32A |
NJIIS Consent to Participate (Spanish)
(updated December 15th, 2022) |
|
|
| IMM-34 |
Site Enrollment Request: Early Hearing Detection and Intervention Program |
|
|
| IMM-35 |
User Enrollment and Training Request: Early Hearing Detection and Intervention Program |
|
|
| IMM-36 |
Vaccines for Children (VFC) Program
New Provider Agreement for Pediatric Sites
(Updated March 22, 2017) |
|
|
| IMM-40 |
New Jersey Immunization Information System (NJIIS)
Duplicate Record |
|
|
| IMM-41 |
NJIIS User Enrollment and Training Request
(updated December 15th, 2022) |
|
|
| IMM-42 |
Enrollment Request for New NJIIS Site
(updated December 15th, 2022) |
|
Instructions (pdf 13k)
|
| IMM-43 |
User Confidentiality Statement for Access to NJIIS/ User Confidentiality Agreement
(updated December 15th, 2022) |
|
|
| IMM-45 |
Request for Change to NJIIS Immunization Record
(updated December 15th, 2022) |
|
|
| IMM-46 |
Request for Copy of NJIIS Immunization Record
(updated December 15th, 2022) |
|
|
| IMM-47 |
Registrant Withdrawal from NJIIS
(updated December 15th, 2022) |
|
|
| IMM-48 |
Vaccines for Children Program
Request to Update Provider Information
(Updated April, 2016) |
|
|
| IMM-PKG-A |
Vaccines for Children (NJVFC) Program
New Provider Enrollment Package (Adult)
(Updated March 22, 2017) |
|
|
| IMM-PKG-P |
Vaccines for Children (NJVFC) Program
New Provider Enrollment Package (Pediatric)
(Updated March 22, 2017) |
|
|
| VAERS |
Vaccine Adverse Event Reporting System: Online |
|
|
Animal Population Control Program
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| APC-4 |
Veterinarian Co-Payment Fee Submission |
|
|
| APC-5 |
Application and Consent for Sterilization of Pets |
|
|
| APC-6 |
Animal Population Control Program
Veterinarian's Agreement (Updated April 23, 2018) |
|
|
| APC-7 |
Payment Voucher / Veterinarian Reimbursement |
|
|
| APC-11 |
Animal Population Control Program Proxy Authorization |
|
|
| VPH-32 |
Application for Animal Control Officer Certification |
|
|
Shelter/Pound Survey Form
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| APC-12 |
Shelter/Pound Annual Report |
|
|
Animal Licensing and Confinement Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| VPH-3 |
List of Licensed Kennels, Pet Shops, Shelters and Pounds |
|
|
| VPH-10 |
Monthly Dog License Report |
|
Instructions
(Updated July 2016) (doc 28k)
Instructions
(Updated July 2016) (pdf 12k)
|
| VPH-11 |
Notice of Animal Bite and Confinement |
|
|
Animal Control and Facility Inspection
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| VPH-1 |
Inspection Report of Kennels, Pet Shops, Shelters, and Pounds |
|
|
| VPH-2 |
Animal Rescue Organization Registration |
|
|
| VPH-20 |
Certification of Veterinary Supervision of the Disease Control and Health Care Program at a Licensed Animal Facility
(Updated May, 2016) |
|
|
| VPH-36 |
License Animal Facility or Animal Control Officer Complaints |
|
|
State/Municipal-Sponsored Rabies Vaccination
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| VPH-23 |
Notice of Intent, State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November 28, 2016) |
|
|
| VPH-25 |
State-Sponsored Municipal Rabies Vaccination Clinic Report
(Updated December 7th, 2021) |
|
Instructions for State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November, 2016) (pdf 9k)
Instructions for State-Sponsored Municipal Rabies Vaccination Clinics
(Updated November, 2016) (doc 23k)
Policies and Guidelines for Animal Rabies Vaccination
(Updated November, 2016) (pdf 11k)
Policies and Guidelines for Animal Rabies Vaccination
(Updated November, 2016) (doc 26k)
|
| VPH-26 |
Rabies Vaccination Certificate |
|
|
| VPH-28 |
Certificate of Exemption from Rabies Vaccination |
|
|
| VPH-35 |
Rabies Testing Notification Form |
|
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