VDH State Forms

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Vital Records & Health Statistics

• Application for Certification of a Vital Record
• ID Requirements for Certification of a Vital Record

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Office of Drinking Water

• Waterworks Permit Application

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Office of Emergency Medical Services

Please see the Files and Forms page on the Office of Emergency Medical Services Web site.

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Office of Environmental Health Services

Bedding and Upholstery Inspection

• Application for Virginia Sanitizer's Permit
• Instructions for Virginia Sanitizer's Permit
• Bedding Manufacturer Inquiry
• Blank License Application
• Blank Permit Application
• Blank Permit Instruction
• Importer Inquiry
• License Application Instruction
• Process to Sanitize Inquiry
• Reupholsterer's Inquiry
• Upholstered Furniture Manufacturer Inquiry

Division of Food and General Environmental Services

• Application for VDH Permit
• Application to Process or Distribute Grade A Milk

Division of Sewage and Water Services

• Alternative Discharging Sewage Treatment Regulations - 12 VAC 5-640-10 et seq. : Effective Date July 30, 1992
• Combined (DEQ-VDH) Application for a Discharging System Permit
• Completion Statement (For Contractors Installing Systems)
  

• AOSE Regulations - 12 VAC 5-615-10 et seq. : Effective July 1, 2002
• AOSE Application
• AOSE Renewal Application
• AOSE Reference
• Soil Evalution
• Soil Profile Description
• Sewage Disposal System Construction Specifications
• Soils Evaluation Percolation Test Data
• Completion Statement (For Contractors Installing Systems)
• Fee Regulations - 12 VAC 5-620-10 et.seq. : Effective Date July 1st, 1989
• Private Well Regulations - 12 VAC 5-630-10 et seq. : Effective Date April 1, 1992
• Application for a Well Construction Permit
• Uniform Well Completion Report
• Sewage Collection and Treatment (SCAT) Regulations
• Sewage Handling and Disposal Regulations - 12 VAC 5-610-10 et seq. : Effective July 1st, 2000
• Application for a Sewage Disposal System Construction Permit
• Application for Sewage Handling Permit
• Application for Pump and Haul Storage Facility Construction Permit
• Physiographic Map of Virginia
• Field Guide to Soil Textures (Appendix F)
• Percorlation Test Procedure (Appendix G)
• Soils Evaluation Percorlation Test Data
• Completion Statement
  

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Office of Epidemiology

Radiological Health Program

Worker Exposure

• Current Occupational Worker Exposure
• Instructions for Preparation of form RH-F-8
• Instructions for Preparation of form RH-F-9
• Previous Occupational Worker Exposure

Radioactive Materials

• Application for Medical use of Radioactive Materials
• Application for Radioactive Materials License (Part I)
• Application for Radioactive Materials License (Part II)
• Instructions for Preparation of form RH-F-4
• Instruction for Preparation of form RH-F-4A
• Instructions for Preparation of form RH-F-13 (Part I)
• Instructions Preparation of form RH-F-13 (Part II)
• In Vitro Diagnostic Testing
• Notices to Employees
• Radioactive Materials License (for illustrative purposes only)
• Supplemental A-Human Use (Part I)
• Supplemental A-Human Use (Part II)
• Supplemental A-Human Use (Part III)
• Source Material (Part I)
• Source Material (Part II)

X-ray Inspection Forms

• Application to be listed as a Private Inspector
• Instructions for Preparation of form RH-F-2
• Operators List
• Registration of X-ray Machines used in the Healing Arts
• Registration of X-ray Machines not used in the Healing Arts
• Report of Installation
  

X-ray Program

• CT Scanners
• Dental Intra-Oral Radiographic Systems
• Dental Panographic X-ray Systems
• Fluoroscopy Radiographic Systems
• General Administrative Report
• General Radiographic Form
• Therapy Machines 1 Mev and Greater
• Therapy Machines Less than 1 Mev
• Veterinary Radiographic Systems

Division of Immunization

• Education Materials Order Form (Immunization)
• School Requirements Forms
• Virginia Vaccines for Children
• Perinatal Hepatitis B Prevention Forms

Division of HIV, STD, and Pharmacy Services

• HIV/STD Form to Request Payment for Services Rendered
• Budget Modification Form
• Community Planning Group Application
• HIV Test Consent Form
• PEMS related Forms
• Literature Request Form
• Resource and Referral Master List
• Resource and Referral Master List Update Form

Tuberculosis Control

• TB Medical Record Forms
• Forms in the VA TB Control Laws Guidebook
• TB Case/Suspect Review
• Contact Investigation Guidelines & Related Forms
• Interjurisdictional TB Notification Referral Form
• Interjurisdictional TB Notification Follow-up Form
• Information from CDC on the International Notification of TB Cases [Opens a new browser]
• International Notification Form
• TB Risk Assessment Form
• Report of TST/X-ray Results
• Clearance Letter for Negative Screen

Virginia Newcomer Health Program

• Refugee and Immigrant Health Assessment Form

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Office of Family Health Services

Division of Dental Health

• School Fluoride Mouthrinse Supply Order Form

Division of Women, Infants and Children(WIC) and Community Nutrition Services

• WIC General Forms and Materials
• WIC Retail Store Management Forms and Materials

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Office of Minority Health and Public Health Policy

• J-1 Guidelines and Application
• Loan Repayment Program Applications
• Virginia’s Nursing Scholarship Applications

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Office of Human Resources

• EEO Complaint Form

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Office of Licensure and Certification

Certificate of Public Need Forms

• Hospital Application
• Outpatient Application
• Compliance with COPN Conditions
• COPN Application Cycle Schedule
  
• Request for Extension or Significant Change Request
  
• Registration Form for Major Medical Equipment
  
• Registration Form for Major Capital Projects
• Long Term Care Instructions
• Long Term Care Application 1
  
• Long Term Care Application 2
  
• Long Term Care Application 3
  
• Long Term Care Application 4
  
• Long Term Care Application 5

Long Term Care Forms

• Bed Change Form for LTC Facilites
• Facility Survey Response
  
• FRI Report Form
  
• LTC Organizational Chart

Home Care and Hospice Forms

• Consent for Home Visit

Home Health Forms & Applications

Renewal Forms for Home Care Organization Licensure

• Instructions for Completing the Renewal Form
  Renewal Form

Initial Forms for Home Care Organization Licensure

• Licensure Application

Other Forms

• Local Zoning Ordinances for Home Care Organization Letter
  
• Surety Bond Requirements for Home Care
  
• Certified Home Health Agency Branch Request
  
• VDH Memo on Criminal Records - Employment Barrier Crimes

Hospice License Forms & Applications

• Hospice Initial or Change License Application
• Hospice License Renewal Application

Hospital License Forms & Applications

• Hospital License Application
• Hospital Initial or chance License Application

Nursing Home License Forms & Applications

• Nursing Home Renewal Application
• Nursing Home Initital or Mid-Year License Application

Outpatient Surgical Hospital License Applications

• Outpatient Surgical Hospital License Application
• Outpatient Surgical Hospital Initial or Chance License Application

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Community Health

• CHS-1A Consent for Health Care - V1 (one signature) English Spanish Arabic Somali
• CHS-1A Consent for Health Care - V2 (two signatures) English Spanish Arabic Somali
• CHS-1B Consent for Special Health Services English Spanish Arabic
• CHS-1C Application & Agreement for Payment Plan English Spanish Arabic

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Office of Chief Medical Examiner

• Declaration of Intent