Medication Disposal Record Form MCAR 023-080-585 Unused, outdated, discontinued, recalled, or contaminated medications, including controlled substances, shall not be kept in the home and shall be disposed of according to federal 82 Homes For Sale in Augusta County, VA. Rahiem Brent. %PDF-1.5 % Service Plan Specific Training (medication trainings), the current payment is $341.54. written medication administration records 4. All over-the-counter medications being administered to the client must have a written physician's order documented in the client's record per Section 17a-210-6. Employee ensured the packaging is secure and put everything back in the medication box. 0000001468 00000 n DDD Medicaid Providers - If your information is inaccurate, click the following link to download the Provider Data spreadsheet. 0000008557 00000 n 75 0 obj <> endobj dY?hG&sEFI, Z!r^tv *GP2|QY#'GlUnzvvRf:*EnxDtN d"a G/O)CFIc@hANwqK.DRtO)~>R>>^pJo3\?%_0'q0~LQo>E/"pO$Kc4h#P|CXvy3 xi7 2j 30230uq00`Xpi\'00``l``r;"7Iu%4of #C endstream endobj 45 0 obj 120 endobj 8 0 obj << /Type /Page /Parent 3 0 R /Resources 9 0 R /Contents [ 20 0 R 24 0 R 26 0 R 28 0 R 30 0 R 32 0 R 34 0 R 36 0 R ] /Rotate 90 /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] >> endobj 9 0 obj << /ProcSet [ /PDF /Text ] /Font << /TT2 14 0 R /TT4 12 0 R /TT6 16 0 R /TT8 17 0 R /TT10 22 0 R >> /ExtGState << /GS1 43 0 R >> /ColorSpace << /Cs6 18 0 R >> >> endobj 10 0 obj << /Type /FontDescriptor /Ascent 905 /CapHeight 718 /Descent -211 /Flags 32 /FontBBox [ -628 -376 2034 1010 ] /FontName /OIIMNH+Arial,Bold /ItalicAngle 0 /StemV 144 /FontFile2 40 0 R >> endobj 11 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 0 /Descent -216 /Flags 34 /FontBBox [ -568 -307 2028 1007 ] /FontName /OIIMOJ+TimesNewRoman /ItalicAngle 0 /StemV 0 /FontFile2 37 0 R >> endobj 12 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 32 /Widths [ 250 ] /Encoding /WinAnsiEncoding /BaseFont /OIIMMG+TimesNewRoman,Italic /FontDescriptor 15 0 R >> endobj 13 0 obj << /Type /FontDescriptor /Ascent 905 /CapHeight 0 /Descent -211 /Flags 96 /FontBBox [ -517 -325 1082 998 ] /FontName /OIIMME+Arial,Italic /ItalicAngle -15 /StemV 0 /FontFile2 38 0 R >> endobj 14 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 114 /Widths [ 278 0 0 556 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 556 0 0 0 0 0 0 0 0 0 0 0 0 611 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 833 0 556 0 0 333 ] /Encoding /WinAnsiEncoding /BaseFont /OIIMME+Arial,Italic /FontDescriptor 13 0 R >> endobj 15 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 0 /Descent -216 /Flags 98 /FontBBox [ -498 -307 1120 1023 ] /FontName /OIIMMG+TimesNewRoman,Italic /ItalicAngle -15 /StemV 0 /FontFile2 42 0 R >> endobj 16 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 121 /Widths [ 278 0 0 0 0 0 0 0 333 333 0 0 0 0 0 278 556 556 0 0 0 0 556 0 0 556 333 0 0 0 0 0 0 722 0 722 722 667 611 0 0 278 0 0 0 833 722 778 667 0 722 0 611 0 0 0 0 0 0 0 0 0 0 0 0 556 611 556 611 556 0 611 0 278 0 556 278 889 611 611 611 0 389 556 333 611 0 0 0 556 ] /Encoding /WinAnsiEncoding /BaseFont /OIIMNH+Arial,Bold /FontDescriptor 10 0 R >> endobj 17 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 32 /Widths [ 250 ] /Encoding /WinAnsiEncoding /BaseFont /OIIMOJ+TimesNewRoman /FontDescriptor 11 0 R >> endobj 18 0 obj [ /ICCBased 39 0 R ] endobj 19 0 obj 1065 endobj 20 0 obj << /Filter /FlateDecode /Length 19 0 R >> stream endobj Developmental Disabilities Administrative Act [20 ILCS 1705/15.4]. Please select a role from drop-down to login. The Division of Developmental Disabilities Quality Improvement Jill Lewis, RN Performance Improvement Nurse Division of Developmental Disabilities Jlewis3@azdes.gov. !CtP]W?z; 0000003946 00000 n DDD Medicaid Providers - If your information is inaccurate, click the following link to download the. Long Term Care Systems, New Jersey Department of Health and Senior Services, who contributed their time, knowledge, and talents to the development and revisions of this . Title: Medication Administration Record (MAR) Last modified by: ltolchin Created Date: 9/5/2008 4:12:00 PM Company: SDRC Other titles: Medication Administration Record (MAR) 6 0 obj << /Linearized 1 /O 8 /H [ 1233 232 ] /L 77911 /E 76007 /N 1 /T 77674 >> endobj xref 6 40 0000000016 00000 n 0000007916 00000 n The Off-Site Medication Form, APD Form 65G-7.009 A, as adopted in rule 65G-7.009, F.A.C. 6iD_, |uZ^ty;!Y,}{C/h> PK ! Author: DDD IT Department. [.-gR\O54 >G7Nl6ebus *b]]G5;BT4R. 0000001144 00000 n DHS Offers Webinar on Newly Released Regulations or call the PPL Customer Service Team at 1-844-842-5891. ; 3. for electronic AND hand-written completion. Google Translate is an online service for which the user pays nothing to obtain a purported language translation. DDD Day Program Manual 11/06 Forms: Form F5 STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES - DIVISION OF DEVELOPMENTAL DISABILITIES Medical Form for Adults Name: _____ Age: _____ DOB: _____ { } Male { } Female . NEW! Month and Year: CODE: 2. 13094 0 obj <> endobj N _rels/.rels ( JAa}7 3 0 obj \Jhzv).q&9Ln+wl!l1Z_1jK3\&OdCpgx1=GoeZr})@T{$W;0HOD#"MS\thh=K8g-R\B$g&C;%+_+L-|@7wahBX.jm=?3~_W1#l B&Nq_q##,_k@1-]5u vo{x!9 KNK 2960 0 obj<> endobj |[ N [Content_Types].xml ( n0ED'(,g6@][D9NP'Q-57,{87[gQ9[b2UJk-VB;%Ad7OCHmc+QX8Fj@V$Vg\:`1;Fcv- ew)d$6O#W@7"VR ? Y*H|KBGByMurUA ~wqNB'ne}r?Fs`j2Ng }M-"4**QoIt'&I[G4@F yu HZ}g=:y!BxduKrtxp`+sz'StJ7'.>\VI?\gHsUO6o , PK ! 0000005583 00000 n Doctors order form (Hold Harmless- signed by physician, parent) (Permission To Retain Form-signed by the physician, parent, and student) The medication in the original pharmacy container. 0000005868 00000 n org provides free access to printable PDF Form MI-1040 is the most common individual income tax return filed for Michigan State residents. 0000005319 00000 n You have multiple roles. 0000025606 00000 n Signatures Employee Name: ____________________________________ Any changes or additional submission processes will be posted to the Department of Health website. Title: iRecord 3.0 User Guide. Stay up to date on vaccine information. hbbd``b`s " aN [Content_Types].xml ( 0HC+JjXEpuIc=mqFPB/{8vo|XtJm?YPX%gdvr}h!dmCjA`D(\F*@z[ 7. Mailing Address: Administrative Office PO Box 726 Trenton, NJ 08625-0726 Office: Department of Human Services building 222 South Warren Street Trenton, NJ 08625-0700 2023 February 2023 February 7, 2023 !!NEW!! ?`:`tOH/_MCJXX;LMV2~=c$ 3(p\w}3vA\$e 05eBQZL 8l/;dz;(Twkmc.>~i7/i !$F?K$+`/G>S%l0UjjPkkkd.59=d]nm0 93y$A\@sZ*RnebmMKcju VZK2ck:F80 WzRejh Duty Area 8: Organize to Administer Medications to Residents 77-80 . Daily Training Records 25. 0000002280 00000 n A medication administration record to document any medications given as instructed in rule 65G-7.008, F.A.C. Service Plan 24. PLEASE ISSUE PRESCRIPTIONS FOR MEDICATION, DIET, ADAPTIVE EQUIPMENT, PROCEDURES AND THERAPIES. fao.b*lIrj),l0%b 0000003054 00000 n 2962 0 obj<>stream 0000002840 00000 n The State of NJ site may contain optional links, information, services and/or content from other websites operated by third parties that are provided as a convenience, such as Google Translate. Use PDF (NEW!) Affirmative Action Survey (optional) 12. 0000001239 00000 n Call NJPIES Call Center for medical information related to COVID. 0000009100 00000 n 0000005111 00000 n . % The PDD can be determined from studies of prescriptions, medical or pharmacy records, and it is important to relate the PDD to the diagnosis on which the drug is used. <<24848f9e8f2e254bbc6cfc72265c29d0>]>> 0000007316 00000 n Asbestos Training Course Proposal Checklist, Survey Report for Mobility Assistance Vehicles (Sample), Survey Report for Ambulance (Basic Life Support) (Sample), Survey Report for Ambulance (Advanced Life Support) (Non-Transport) (Sample), Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample), Quarterly Report of Specialty Care Transport Units, Application for Accreditation - Emergency Medical Technician Education Program, Application for Certification as an Emergency Medical Technician-Basic Instructor, Emergency Medical Technician Training Fund Final Reimbursement Report, Emergency Medical Technician (EMT) Training Fund Certificate of Eligibility for EMT Education, EMT & Paramedic Clinician Reciprocity Application Verification of EMT & Paramedic Education and Licensure, New Jersey Medical Reserve Corps User Enrollment Request, Registration of Drug or Medical Device Manufacturing or Wholesale Drug or Medical Device Business, Bulk and Bottled Water Establishment Application, Initial Application for License to Operate a Refrigerated Warehouse and/or Locker Plant, Initial Application for License to Operate a Non-Alcoholic Beverage Manufacturing Plant, Application for Certificate of Free Sale (CFS), Renewal or Discontinuation Application to Operate a Wholesale Drug or Medical Device Business, Application for Permit to Handle Nitrous Oxide, Renewal Application to Operate a Refrigerated Warehouse-Locker Plant, Initial Application for License to Operate a Wholesale Food-Cosmetic Establishment, Retail Food Inspection Report (Local Health Departments), Risk-Based Inspection Report (Local Health Departments), Renewal Application to Operate a Non-Alcoholic Beverage and/or Bottling Plant, Renewal Application to Operate a Wholesale Food/Cosmetic Establishment, Renewal Application for Certification to Sell Bottled Water or Bulk Water, Application for Certification to Handle Oysters, Clams or Mussels, Individualized Family Service Plan (IFSP), Initial Uniform Application for Services to Individuals 21 and Under with Developmental Disabilities, Withdrawal of Dispute Resolution Request (formerly titled "Withdrawal of Complaint"), Family Cost Participation Application for Income Adjustment, Family Cost Participation Income Documentation, Family Cost Participation - Payment Options, Family Cost Participation Tables - SFY 2023 Hourly Co-Pay, Certificate of Free Sale Package (English) (including F-L3 and F-12 Forms), Certificate of Free Sale Package (Spanish) (including F-L4 and F-12 Forms), EMPLOYEE IDENTIFICATION (BUILDING/PARKING) MULTIFORM, Statement of Interest Earned from Advance Payments Deposited into an Interest Bearing Account, Grant Application Package - Construction Grant (FS-26), Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility (for use on or after January 1, 2007) (formerly HCQO-19), Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility - Root Cause Analysis (RCA) (for use on or after January 1, 2007) (formerly HCQO-20), Daily Patient Care Staffing: Inpatient Units, Daily Patient Care Staffing - Inpatient (Spanish), Daily Patient Care Staffing: Emergency Department, Daily Patient Care Staffing - Emergency Department (Spanish), Daily Patient Care Staffing: Post-Anesthesia Care Unit, Daily Patient Care Staffing - Post Anesthesia Care Unit (PACU) (Spanish), Daily Patient Care Staffing-Other Licensed Health Care Professionals: Hospital-Wide, Daily Patient Care Staffing - Other Licensed Health Care Professionals, Hospital Wide (Spanish), Open Heart Surgery Risk Stratification Project - Data Collection Form, Version 4.3, Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment, Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership, Specimens for Newborn Biochemical Screening, Order form for Initial Newborn Screening Request (IEM-1) Forms, Annual College Immunization Status Report, Standard School/Child Care Center Immunization Record, Retrospective Immunization Audit / Survey, Provisional Admittance Student Tracking Record, Confidential Perinatal Hepatitis-B Case and Contact Report, New Jersey Immunization Information System (NJIIS), Site Enrollment Request: Early Hearing Detection and Intervention Program, User Enrollment and Training Request: Early Hearing Detection and Intervention Program, NJIIS User Enrollment and Training Request, User Confidentiality Statement for Access to NJIIS/ User Confidentiality Agreement, Request for Change to NJIIS Immunization Record, Request for Copy of NJIIS Immunization Record, Request for Medical Exemption From Mandatory Immunization, Application to Continue Human Subjects Research, Application to Modify Human Subjects Research, Request for Microbiological Testing of Food Sample, Request for Testing of Suspected Pathogens of Public Health Significance and Chain of Custody, Application for the Addition of Long-Term Care Beds, Facility Reporting Incident Data and Analysis Yield (FRIDAY), Application for a Long-Term Care Facility License, Application for Registered Environmental Health Specialist Examination, Application for Health Officer Examination, Uniform Shared Services Agreement (Template) for Local Public Health Services, Red Book-Local Health Emergency Contact Directory, Report of Childhood Blood Lead Analysis by Independent Laboratory (for children 16 years of age and under), Notification form Long-Term Care Facility of Admission or Termination of a Medicaid Beneficiary, Application for a Milk Plant or a Bulk Milk Hauler (BTU) Permit, License to Manufacture Frozen Desserts Establishment Application, Renewal Application to Operate a Frozen Dessert Plant. o~^t|??hM2Wto>?y Y2t"rc. DDD Provider Agreement - (DDD-PA 01-03-2019) 8. Discontinuing Medications Demonstrates competency in agency policies and practices for proper documentation of the discontinuation of a medication 5. Google Translate is an online service for which the user pays nothing to obtain a purported language translation. fillable PDF form - use Adobe Reader (click to download Reader), Instructions for Completing the PHSS-5 Payment Voucher, Guidelines (Guia), (English/espaol) (REG-D34), Instructions for Completion of TB-70 Form, Instructions for Submission of Specimens (packaging and transport), Instructions for State-Sponsored Municipal Rabies Vaccination Clinics, Policies and Guidelines for Animal Rabies Vaccination. Medication Administration - "You Are Your Brother's Keeper" N _rels/.rels ( JAa}7 trailer << /Size 46 /Info 4 0 R /Root 7 0 R /Prev 77665 /ID[<0c226b5500007d2f0ee1517cbce23df1>] >> startxref 0 %%EOF 7 0 obj << /Type /Catalog /Pages 3 0 R /Metadata 5 0 R /PageLabels 2 0 R >> endobj 44 0 obj << /S 36 /L 133 /Filter /FlateDecode /Length 45 0 R >> stream 0 A copy of the Agency's form "Medication Administration Record," APD Form 65G7-00 (3/30/08), incorporated herein by reference, may be obtained by writing or calling the Agency for Persons with Disabilities, at 4030 Esplanade Way, Suite 380, Tallahassee, FL 32399-0950; main phone number (850)488-4257. The State of NJ site may contain optional links, information, services and/or content from other websites operated by third parties that are provided as a convenience, such as Google Translate. Medication Administration Record (MAR) Form D.401. !WWE` & endstream endobj 25 0 obj 505 endobj 26 0 obj << /Filter /FlateDecode /Length 25 0 R >> stream For more information and to review Training Reimbursement Payment FAQ, please visit PPL's NJ DDD Program webpage at . Duty Area 6: Medication Administration Records (MARs) and other forms 61-68 . {0W\93*-ajwB}2M1C:4\#{p3gzQ1.vg6~dA<4?A;@R^gi7@|O1yZyG$#l]L< R95~NBUWb8)'j Mock Medication Administration Observation Checklist (Initial Only-Not Required for Recertification) Areas of Demonstration Mock Trial CommentsDate: Yes No 1. Medication 20A Prescription Medication 20B PRN (as needed) Prescription Medication 20C PRN Over the Counter (OTC) Medication 20D Medication Storage 20E Medication Administration 21. Application for an Uncertified Copy of an Adopted Person's Original Birth Record, Marriage Template (long form with Parents' Names), Marriage Template (short form without Parents' Names), Civil Union Template (without Parent Names), Request for Legal Name Change to Original Record of Birth, Marriage, Civil Union or Domestic Partnership, Correcting a Birth Record for Out-of-Wedlock Child Whose Mother Married a Man Other Than the Natural Father, Correcting the Birth Record of a Child Said to Have Been Born Out-of-Wedlock and Whose Natural Parents Have Not Married Each Other, Request to Purchase Certified Copy of Vital Records Forms, Request to Place on File a Certificate of Birth Resulting in Stillbirth, Quarterly Report of Non-EDRS Burial Permits Issued, Application for License: Marriage, Remarriage, Civil Union, or Reaffirmation of Civil Union, Application for License: Marriage, Remarriage, Civil Union or Reaffirmation of Civil Union (Combined English and Spanish), Notice of Rights and Obligations of Domestic Partners, Notice of Rights and Obligations of Domestic Partners (Spanish), "Entering into a Marriage or Civil Union in New Jersey" Brochure, "Entering into a Marriage or Civil Union in New Jersey" Brochure (Spanish), "Entering into a Marriage or Civil Union in New Jersey" Brochure (Russian), "Entering into a Marriage or Civil Union in New Jersey" Brochure (Korean), "Registering a Domestic Partnership in New Jersey" Brochure, "Registering a Domestic Partnership in New Jersey" Brochure (espaol), "Registering a Domestic Partnership in New Jersey" (Russian), "Registering a Domestic Partnership in New Jersey" (Korean), Guidelines for Requesting to Place on File a Certificate of Birth Resulting in Stillbirth (English/espaol), Request Form and Attestation to Amend Sex Designation on a Birth Certificate for an Adult to Reflect Gender Identity, Parent/Guardian Request Form and Attestation to Amend Sex Designation on a Birth Certificate for a Minor to Reflect Gender Identity, Special Child Health Services Registration Form, Critical Congenital Heart Defects Screening Program, Notice of Availability of Supplemental Newborn Screening, Notice of Availability of Supplemental Newborn Screening (spanish), Online Spinal Cord Research Grant Applications, Request for Viral Serology, Culture and Molecular Diagnostics, Request for Immunological/Isolation Services - Clinical Services Testing Unit, Confidential Sexually Transmitted Disease Report, Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (SUD), APPLICATION FOR NEW OR AMENDED RESIDENTIAL SUBSTANCE USE DISORDER TREATMENT FACILITY LICENSE N.J.A.C. <> %PDF-1.3 % trailer Application and Consent for Sterilization of Pets, Payment Voucher / Veterinarian Reimbursement, Animal Population Control Program Proxy Authorization, Rehabilitative Hospital and Special Hospital subject to a $10 Adjusted Admission Assessment, Asbestos Management Plan, Room/Functional Space Inspection, Request for Bacterial or Viral Culture or Parasite Identification, Application For Certificate of Approval To Operate a Youth Camp, Application For Certificate of Approval To Operate a Single Sport Youth Camp, Annual Accident Report Youth Camp Safety Act, Youth Camp Self-Inspection Report (for Youth Camp Operators), Youth Camp Safety Detailed Data Sheet (for Local Health Inspectors), Youth Camp Safety Detailed Data Sheet (for Youth Camp Operators), Certification for the Replacement of Main Drain Covers in Pool/Spa, Pediatric HIV Confidential Case Report Form, Typhoid And Paratyphoid Fever Surveillance Report, Cholera And Other Vibrio Illness Surveillance Report, Multisystem Inflammatory Syndrome Associated with COVID-19: Case Report Form, For Reporting Reportable Communicable Diseases, Patient Symptoms Line Listing (Respiratory Tract Infection), Patient Symptoms Line Listing (Gastrointestinal Infection). Employee washed hands and gathered all necessary supplies (e.g. Augusta, NJ 07822 Subject: Medication Departments Affected: All Programs Effective Date: 3/1/19 Replaces Policy: 10/9/87; 2/23/90; 4/15/92 . 4 0 obj 6iD_, |uZ^ty;!Y,}{C/h> PK ! 0000018364 00000 n HCANJ | New Jersey (NJ) NursingCenter and Assisted Living Providers Search arrest records and find latests mugshots and bookings for Misdemeanors and Felonies. The CDS training module has been updated with NJ specific content and annotations to ensure staff are familiar with NJ policies and regulations as noted in the classroom training. x][oH~Gja/I`cgfd'>}-$j$9TUwSVb %W]]O7Mu;iNfr3MNN\NLu:Lgo$Qe2_7? 0000009724 00000 n Notice to Enrollee 11. To receive Division Circulars, special alerts related to Division Circulars, and regulation updates by email, send a request to DDD-CO.LAPO@dhs.nj.gov and include your name, email address, and affiliaton (agency, individual, family, advocate, etc.) Hn$1aOaS\.,&,$rEc,h>uJWJ!Uj2Ky 3e5bFe3YO1Q"T7k!lUb. endstream endobj startxref 0000000016 00000 n 0000002067 00000 n Catastrophic Illness in Children Relief Fund (CICRF), Commission for the Blind & Visually Impaired (CBVI), Division of the Deaf & Hard of Hearing (DDHH), Division of Developmental Disabilities (DDD), Division of Medical Assistance & Health Services (DMAHS), Division of Mental Health and Addiction Services (DMHAS), Office for Prevention of Developmental Disabilities, Office of Program Integrity & Accountability, Public Advisory Boards, Commissions & Councils, Office of Education of Self-Directed Services. 0000000693 00000 n <>/Metadata 553 0 R/ViewerPreferences 554 0 R>> %%EOF Hemolytic Uremic Syndrome (Postdiarrheal) Report, Epidemiology Surveillance Record (Hospital-Based Laboratory), Report of Known or Suspected Avian Chlamydiosis (Psittacosis), Outbreak Report for Long Term Care and Other Institutions, Outbreak Report for Child Care, School and Camp Settings, Child Care Center - DOH Subsequent Notification, Statement of Education and Experience Requirements, Checklist for Public Recreational Bathing Facilities, Notification of Non-Friable Asbestos Work Activities, Notification of Non-Friable Asbestos Work Activities Related to Superstorm Sandy, Contractor Information for Non-Friable Asbestos Work Activities, Body Art or Ear-Piercing Establishment Report of Infection or Injury, Physician Report Form (Non-Hospital Source), Application for Cottage Food Operator Permit, Child Health Conference - Health Assessment (Infancy: 2-6 Weeks), Child Health Conference - Health Assessment (Infancy: 2 Months), Child Health Conference - Health Assessment (Infancy: 4 Months), Child Health Conference - Health Assessment (Infancy: 6 Months), Child Health Conference - Health Assessment (Infancy: 9 Months), Child Health Conference - Health Assessment (Infancy: 12 Months), Child Health Conference - Health Assessment (Childhood: 15 Months), Child Health Conference - Health Assessment (Childhood: 18 Months), Child Health Conference - Health Assessment (Childhood: 2 Years), Child Health Conference - Health Assessment (Childhood: 3 Years), Child Health Conference - Health Assessment (Childhood: 4 Years), Child Health Conference - Health Assessment (Childhood: 5 Years), Child Health Conference - Health Assessment (Childhood: 6 Years), Child Health Conference - Health Assessment (Childhood: 7 Years), Child Health Conference - Health Assessment (Childhood: 8 Years), Child Health Conference - Health Assessment (Childhood: 9 Years), Child Health Conference - Health Assessment (Childhood: 10-12 Yrs), Child Health Conference - Health Assessment (Childhood: 13-15 Yrs), Child Health Conference - Health Assessment (Childhood: 16-20 Yrs), Child Health Services Quarterly Summary Report, Care Plan for Children with Special Health Needs, Organic and Inorganic Chemistry Sample Submittal, Application for a Clinical Laboratory License, Blood Bank Annual Statistics (Out of Hospital and Emergency Only Transfusion Facilities), Disclosure of Ownership and Control Interest, Blood Bank Annual Statistics (Umbilical Cord Blood Facilities), Laboratory Personnel Qualification Appraisal, Blood Bank Personnel Qualification Appraisal, Brokers and Reagent Manufactureres - Annual Statistical Data, Request for Funding from Civil Monetary Penalties, Clinical Laboratory Improvement Amendments (CLIA) Application for Certification, Full Review Certificate of Need Application for Long Term Care Facilities: General Long Term Care Beds; Specialized Long Term Care Beds, Application for Certificate of Need for Hospital-Related Projects, Application for Certificate of Need for Designation as a Perinatal Facility, Project Application for an Adult Day Health Services Facility, Application for New or Amended Acute Care Facility License, Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility, Health Care Facility Inquiry Regarding Health Care Professional (HFEL-9) (updated August 10,2017), Annual Report of Megavoltage Radiation Unit, Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership (Formerly HFEL-8), Certificate of Need Application-Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a), HIV Confidential Consent Form (Serology) (spanish), HIV Consent (Rapid Testing) - Confidential and Anonymous Testing, HIV Consent (Rapid Testing) (Confidential and Anonymous) (spanish), HIV Consent (Rapid Testing) (Confidential and Anonymous) (Creole), HIV Consent (Rapid Testing) - Confidential Testing Only, HIV Consent (Rapid Testing) (Confidential Only) (spanish), HIV Consent (Rapid Testing) (Confidential Only) (Creole), Application for Eligibility for the HIV Home Care Program, Pediatric HIV/AIDS Confidential Case Report, Renewal Application for Lead Training Agency Certification, Initial Application for Asbestos Training Agency Certification, Renewal Application for Asbestos Training Agency Certification, Application for Reciprocal Asbestos Accreditation, Application for Approval as a NJ Asbestos Course Instructor, Application for Approval as a NJ Lead Course Instructor/Training Manager, Application for Lead Permit Worker-Housing and Public Buildings, Application for Lead Permit Supervisor, Housing and Public Buildings, Application for Lead Permit Inspector/Risk Assessor, Application for Lead Permit Planner/Project Designer, Application for Lead Permit Worker, Commercial Buildings and Superstructure, Application for Lead Permit Supervisor, Commercial Buildings and Superstructures, Initial Application for Lead Training Agency Certification, Application for Replacement of Lead Permit. ; 4. Application for Temporary Marketing Permit: Renewal Application to Operate a Bulk Tank Unit/Milk Plant, Mental Health Professional Compliance Form, Request for Medication To End My Life in a Humane and Dignified Manner, Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (MH), Faithful Families Eating Smart and Moving More, Application for Approval of a Certified Medication Aide Training and Competency Evaluation Program (MATCEP) in Assisted Living Residences / Assisted Living Programs / Comprehensive Personal Care Homes, Addendum: CMA Training - List of Course Attendees, Application for Nursing Home Administrator License, Sponsor Application for Continuing Education Program Approval for Licensed Nursing Home Administrators, Application for Approval of Administrative Intern Program, Certification of Program Completion for Nursing Home Administrative Intern Program, Institutional Approval of Intramural Research, Agreement for Ethical Conduct of Human Subjects Research, Agreement for Ethical Conduct of Human Subjects Research (Federal Employees), Notice of Claim of Exemption of Tobacco Retail Establishment, Application for Registration of Exempt Cigar Bar or Lounge, Application for Renewal of Registration of Exempt Cigar Bar or Lounge, NJ Smoke Free Air Act / Anonymous Request for Investigation, Public Employees Occupational Safety and Health (PEOSH) Unit Request for On-Site Consultation, EMS Respiratory Protection Program Evaluation Questionnaire, PEOSH Respirator Medical Evaluation Questionnaire, Firefighter Respirator Medical Evaluation Questionnaire, Documentation of Medical Evaluation for Respirator Use, Occupational and Environmental Disease, Injury, or Poisoning Report by Health Care Provider, Firefighter SCBA After Use/Daily Inspection Checklist, Clinical Laboratory Report of Elevated Levels of Heavy Metals:Lead: In Adults (Greater than 16 Years of Age)Arsenic, Cadmium, Mercury: In Persons of Any Age, PEOSH Hazard Communication Standard, Documentation of Training, Sample Letter for Requesting Safety Data Sheets (SDS's), Worker and Community Right to Know Act / Employer Outreach Survey, Quarterly Report of RTK County Lead Agencies, Public Employees Occupational Safety and Health (PEOSH) Unit Complaint, J-1 Visa Waiver / State Conrad 30 Program - Physician-Primary Care Survey, Initial/Biannual Service Report, J-1 Visa Waiver / State Conrad 30 Program - Application for New Jersey, Attachment A: Current Medical Staffing at Practice Site, Attachment B: Health Care Resources Inventory, Attachment C: Facility Current Sliding Fee Scale, Attachment D: J-1 Physician Visa Waiver / State Conrad 30 Program - Statements, Section 4-1, Health Facility's J-1 Visa Waiver / State Conrad 30 Program - Agreement, Section 4-2, Physician J-1 Visa Waiver / State Conrad 30 Program - Affidavit and Agreement, Section 5, J-1 Visa Waiver Required Application Enclosures, American Cancer Society (ACS) Monthly Activity Report, Mom's Quit Connection (MQC) Monthly Activity Report, Requisition for Printing and Graphic Design, Application for Tanning Facilities Registration, Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects, Confidential Medical Waste Exposure Report, Questionnaire to Assess Your Exposure Risk for Lead and Mercury (Quicksilver), Radioanalytical Services Sample Submittal, Quarterly Report of Domestic Partnerships Registered, Delegation of Authority to Receive Certified Copy of Vital Record (Birth/Death), Delegation of Authority to Receive Certified Copy, Report of No Births, Marriages, Civil Unions, Domestic Partnerships or Fetal Deaths, Application for a Certified Copy of a "No Record of Marriage" Statement (English/Spanish), Certified Municipal Registrar Recertification Course Tracking Log, Application to Amend a New Jersey Vital Record /, Authorization for Release of Cause of Death, APLICACIN PARA COPIAS CERTIFICADAS CERTIFICACIONES DE REGISTROS CIVILES, APLICACIN POR UNA COPIA CERTIFICADA CERTIFICACIONES DE UN REGISTRO CIVIL, Correcting a Birth Record for Child Whose Natural Parents Married After Its Birth. 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