Illinois Department of Public Health Forms

This form is used for conducting lead assessments by public health nurses in the state of Illinois.

This document provides a sample general letter for Illinois parents/guardians regarding measles.

This Form is used for applying to become a board member in Illinois.

This document certifies that a product is freely available for sale in the state of Illinois.

This document is used for registering a body art establishment or applying for a tanning facility permit in the state of Illinois.

This Form is used for agencies in Illinois to apply for recertification as an Emergency Medical Dispatch Agency.

This Form is used for applying for reciprocity in Illinois.

This form is used for requesting resources or supplies from the local health department in Illinois.

This form is used for lodging complaints about health care facilities in the state of Illinois.

This document is used for submitting samples to the IDPH Vectorborne Laboratory in Illinois for testing and analysis.

This document outlines a plan for the treatment and support of survivors of sexual assault in the state of Illinois. It includes information on counseling, medical care, legal resources, and other support services available to survivors.

This Form is used for developing a treatment plan and transferring pediatric patients who have experienced sexual assault in Illinois. It helps ensure comprehensive and appropriate medical care for the victims.

This document outlines the process for transferring sexual assault cases in Illinois. It provides guidelines and procedures for ensuring the safety and well-being of victims as they move through the legal system.

This form is used for recording and ordering lead program contact information in the state of Illinois.

This document is a questionnaire used in Illinois to assess the risk of childhood lead exposure.

This form is used for biological mothers in Illinois to submit an affidavit.

This form is used for applying for a Designated Caregiver Registry Identification Card Attestation in the state of Illinois. The card allows individuals to serve as designated caregivers for patients who are registered in the Illinois Medical Cannabis Program.

This Form is used for applying for a Registry Identification Card in Illinois for qualifying patients under 18 years of age and their designated caregiver.

This form is used for requesting an increase in the allotment of medical cannabis for a registered qualifying patient in Illinois.

This form is used for obtaining a school dental exam record in Illinois. It is in Spanish.

This form is used for reporting the results of a blood lead test in the state of Illinois. It is important for monitoring lead exposure in individuals.

This form is used to apply for pre-approval of oral Valcyte medication assistance through the Ryan White Part B ADAP Medication Assistance Program in Illinois. It helps individuals receive financial assistance for Valganciclovir Hydrochloride, a medication used to treat certain viral infections.

This document is the application form for pre-approval of Hepatitis C medication assistance under the Ryan White Part B Adap Medication Assistance Program (MAP) in Illinois.

This form is used for applying for a professional license in the state of Illinois.

This form is used for physicians in Illinois to confirm a patient's terminal illness.

This Form is used for Designated Caregiver Attestation in Illinois. It provides instructions on how to complete and submit the form required for someone to become a designated caregiver.

This Form is used for applying for a Registry Identification Card in Illinois.

This document is for applying for a Registry Identification Card in Illinois for individuals diagnosed with a terminal illness. The card is valid for six months only.

This form is used for reporting cases of lung injury associated with vaping in the state of Illinois.

This document provides information on the inspection report for food establishments in Illinois. It includes details on the hygiene and safety measures taken by the establishments.

Este documento es una orden para los practicantes de atención médica en Illinois que indica cómo completar el formulario de Tratamiento de Vida Sostenible (POLST por sus siglas en inglés). El POLST es un documento legal que especifica los deseos de atención médica de una persona en situaciones de emergencia.

This form is used for requisitioning clinical supplies in the state of Illinois. It is specifically designed for the IOCI19-643 program.

This form is used for requesting a Covid-19 laboratory test in the state of Illinois.

This form is used for health care workers in Illinois to apply for a waiver.

This form is used for applying to make changes to a manufactured home community in Illinois.

This document is for applying to establish a manufactured home community in the state of Illinois. It includes information and requirements for obtaining a permit or license for this type of community.

This form is used for renewing the license for a migrant labor camp in the state of Illinois. It is important for ensuring the safety and well-being of migrant workers.