Indiana State Department of Health Forms

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Documents:

153

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This document is used for requesting a referral for an assessment or consultation in the state of Indiana.

This form is used for requesting contact information of immunization providers in Indiana.

This document is for the Long-Term Care Visitor and Staff Screening Tool used in Indiana. It helps screen visitors and staff members entering long-term care facilities for potential health risks.

This form is used to apply for a marriage license in the state of Indiana.

This form is used for reporting confidential information about communicable diseases in the state of Indiana.

This form is used for tracking and monitoring blood pressure levels in Indiana. It provides a visual representation of optimal and abnormal blood pressure ranges.

This form is used for applying to become a wild mushroom identification expert in Indiana.

This form is used for requesting a medical exemption from vaccination in the state of Indiana.

This document is utilized for initial evaluation of individuals seeking admission for Substance Use Disorder Treatment in Indiana health coverage programs. It is beneficial for understanding the patient's condition and treatment needs.

This document is used to track the temperature of refrigerators and freezers in Indiana. It helps ensure that food is stored at the appropriate temperature to maintain safety and quality.

This document is used for recording and tracking the temperature of refrigerators and freezers every 12 hours in Indiana. It is essential for ensuring food safety and compliance with health regulations.

This form is used for requesting an exemption from vaccination requirements in the state of Indiana. It allows individuals to provide a valid reason for not getting vaccinated, such as medical or religious beliefs.

This document is for demonstrating the need for oxygen therapy as deemed necessary by a licensed healthcare provider in Indiana. Its purpose is to facilitate insurance coverage or reimbursement for oxygen equipment and supplies.

This form is used by healthcare providers in Indiana to request special orders of vaccines. It is essential for ensuring proper vaccine distribution and inventory management in the state.

This Form is used for enrolling in the Indiana Outpatient Influenza-like Illness Surveillance Network (ILINet). ILINet is a system that monitors and tracks influenza-like illnesses in Indiana. By enrolling, individuals contribute to important data collection on the spread of influenza in the state.

This checklist is used for documenting the entrance conference at a hospital or critical access hospital (CAH) in Indiana.

This document provides a checklist for the entrance conference documentation required for Ambulatory Surgical Centers (ASC) and End Stage Renal Disease (ESRD) facilities in Indiana.

This document is a checklist used in Indiana for conducting entrance conferences regarding life safety code compliance for ICF/DD (Intermediate Care Facility for Individuals with Intellectual Disabilities). It ensures that proper documentation is in place to address safety measures in these facilities.

This document is used for investigating cases of monkeypox in Indiana. It is a form that gathers crucial information about the patients and helps health officials track and contain the spread of the disease.

This form is used for healthcare facilities in Indiana to apply for the renewal of their license. It is required to ensure that these facilities meet the necessary standards and regulations to operate in the state.

This form is used for changing the administrator or director of nursing in the state of Indiana.

This Form is used for applying for a license to operate a health facility in the state of Indiana.

This Form is used for submitting a Plan Review Questionnaire in the state of Indiana.

This form is used for reporting visa or Vrsa (Violent School Incident) incidents in the state of Indiana. It is a document designed to track and document any incidents related to visas or violent incidents in schools.

This form is used for reporting and tracking infections when transferring patients between healthcare facilities in Indiana.

This document is used for reporting CPO (Chemical/Contamination Prevention Officer) information in the state of Indiana.

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