Forms
- Communicable Disease
- Fireworks Injury Reporting
- HIPAA
- Immunization
- Laboratories
- Medical Radiology
- Morbid Obesity Surgical Forms
- School Screening
- Vital Records/Birth/Death Certificates
Communicable Disease
- Adult HIV/AIDS Confidential Case Report
- Animal Bites Report - State Form 14702 (R3/4-04)
- Anthrax Case Investigation - State Form 51641 (7-04)
- Application and Claim for Biologicals - State Form 43918 (R/11-97)
- Babesiosis Case Investigation - State Form 52135 (5-05)
- Blood or Body Fluid Exposure, Notification of - State Form 51467 (9-03)
- Botulism Case Investigation - State Form 49684 (R2/1-05)
- Brucellosis Case Investigation - State Form 51639 (7-04)
- Campylobacteriosis Case Investigation - State Form 49685 (R2/1-05)
- Cholera/Vibriosis Case Investigation - State Form 49686 (R2/1-05)
- Confidential Report of Communicable Diseases - State Form 46823 (R2/11-96) Information on reporting STDs
- Cryptococcosis Case Investigation - State Form 52276 (8-05)
- Cryptosporidiosis Case Investigation - State Form 49687 (R2/1-05)
- Cyclosporosis Case Investigation - State Form 49688 (R2/1-05)
- E. Coli 0157:H7 - Hemolytic Uremic Syndrome - State Form 49689 (R2/1-05)
- Hansens Disease - State Form 52139 (5-05)
- Hepatitis A Case Investigation - State Form 49690 (R2/1-05)
- Hepatitis B and Delta Hepatitis Case Investigation - State Form 52587 (2-06)
- Hepatitis C Case Investigation - State Form 52588 (2-06)
- Hepatitis E Case Investigation - State Form 49691 (R2/1-05)
- Histoplasmosis Case Investigation - State Form 52253 (7-05)
- Influenza-Associated Deaths Case Investigation - State Form 52576 (2-06)
- Influenza Lab Submission - State Form 52419 (10-05)
- Legionellosis Case Investigation - State Form 49817 (R1/4-05)
- Leptospirosis Case Investigation - State Form 52346 (8-05)
- Listeriosis Case Investigation - State Form 49692 (R2/1-05)
- Lyme Disease Case Report - State Form 51933 (10-04)
- Meningococcal Disease, Suspect Invasive - State Form 51000 (R/10-05)
- Meningitis, Suspect Aseptic, Case Investigation - State Form 51001 (R/5-05)
- Mosquitoborne Encephalitis Case Investigation - State Form 51382 (R/4-04)
- Pediatric HIV/AIDS Confidential Case Report - State Form 51202 (12-02)
- Plague Case Investigation - State Form 51642 (11-04)
- Perinatal Hepatitis B Case Investigation - State Form 52589 (2-06)
- Q-Fever Case Investigation - State Form 51657 (7-04)
- Rabies Post Exposure Treatment, Report of - State Form 51726 (10-04)
- Report of Treatment for Latent TB, SF 49894 (R2/9-03)
- Report of Tuberculosis, SF 14058 (R6/9-03)
- Request for TB Drugs, SF 48085 (R5/10-04)
- Rocky Mountain Spotted Fever Case Investigation - State Form 52684 (6-06)
- Salmonellosis Case Investigation - State Form 49693 (R2/1-05)
- Severe Staphylococcus Aureus Infection in a Previously Healthy Person Case Investigation - State Form 53653
- Shigellosis Case Investigation - State Form 49694 (R2/1-05)
- Streptococcal Toxic Shock Syndrome - and
Streptococcus, Group A, Invasive (GAS) - State Form 50998 (R/10-05) - Streptococcus, Group B, Invasive (GBS) - State Form 50999 (R/10-05)
- Streptococcus Pneumoniae Case Investigation - State Form 49218 (R/11-04)
- TB - Contact Investigation Report
- TB - Hospital Reimbursement Claim
- TB - Monthly TB Follow Up Report
- TB - Report of Treatment for Latent TB Infection
- TB - Report of Tuberculosis
- TB - Request for TB Drugs
- TB - Tuberculosis Waiver Request
- Toxic Shock Syndrome (TSS) Case Investigation - State Form 51002 (R/10-05)
- Trichinosis Case Investigation - State Form 49695 (R2/1-05)
- Tularemia Case Investigation - State Form 51638 (7-04)
- Typhoid Fever Case Investigation - State Form 49696 (R2/1-05)
- Vaccine Administration Record, SF54642 (05-06)
- Varicella (Chickenpox) Disease Surveillance Monthly Report
- Varicella (Chickenpox) Sentinel Surveillance System - Enrollment
- Varicella (Hospitalized) Case Investigation - State Form 49943 (R/7-05)
- Yersiniosis Case Investigation - State Form 49697 (R2/1-05)
Fireworks Injury Reporting Form
Download the Fireworks Injury Reporting Form (State Form 51497) and either Fax or mail to the Indiana State Department of Health.
Fireworks Injury Reporting Form
Please fax this form to (317) 233-7805; Attn: Injury Epidemiologist
Or mail to: Indiana State Department of Health
2 North Meridian Street, 6A
Indianapolis, IN 46204
Please direct any calls to (317) 234-2888 or 233-7960
HIPAA
Immunization
- Temperature Log for Vaccines (Celsius)
- Temperature Log for Vaccines (Fahrenheit)
- Refusal To Vaccinate
- Screening Questionnaire for Adult Immunization
- Screening Questionnaire for Child and Teen Immunization
- Vaccine Administration Record for Adults
- Vaccine Administration Record for Children and Teens
- Vaccine Adverse Event Reporting System
- Vaccine Information Statements Q and A
Laboratories
Clinical
- Enteric Bacteriology
- Enteric Reference Culture
- Mycobacteriology
- Mycology Test Request
- Parasitology
- Pertussis DFA and Culture
- Rabies Examination
- Reference Bacteriology Culture Identification
- Virology
Environmental
- Chemical Examination of Water
- Instructions for Fluoride/Sodium Water Sample
- Instructions for Nitrite Sample Collection
- Instructions for Total Nitrate/Nitrite Sample Collection
- Private Water Supply Report
- Public Water System Report
Medical Radiology
- Application for Radiology License or Permit
- Application for Approval of Radiology Program
- Certification of Proficiency for Limited Radiographer
Morbid Obesity Surgical Forms
- Surgery for the Treatment of Morbid Obesity - Initial Report (State Form 53321)
- Surgery for the Treatment of Morbid Obesity - Follow-Up Reports (State Form 53322)
School Screening
- School Scoliosis Screening Report State Form 4685 (R4/4-06)
- Vaccine Administration Record, SF54642 (05-06)
Vital Records/Birth/Death Certificates
Adoption
- Identifying Information Indiana Adoption History Registration - State Form 47896 (R3/6-05)
- Non-Identifying Information Indiana Adoption History Registration - State Form 47897 (R3/6-05)
- Indiana Adoption Medical History Report - State Form 9966 (R4/10-05)
- Record of Adoption (State Form 05438)
- Indiana Putative Father Registration (State form 46750)
- Adoption History Registration Program Birth Parent Nonrelease Form (State Form 46392)
Birth
Death
Marriage
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