Forms

• Communicable Disease
• Immunization
• Laboratories
• Medical Radiology
• School Screening
• Vital Records/Birth/Death Certificates

Communicable Disease

• Adult HIV/AIDS Confidential Case Report
• Animal Bites Report - State Form 14702 
• Babesiosis Case Investigation - State Form 52135 
• Blood or Body Fluid Exposure, Notification of - State Form 51467   
• Confidential Report of Communicable Diseases - State Form 43823 
• Hepatitis B and Delta Hepatitis Case Investigation - State Form 52587 
• Hepatitis C Case Investigation - State Form 52588 
• Histoplasmosis Case Investigation - State Form 52253 
• Online Indiana Confidential Sexually Transmitted Disease Report - State Form 56459
• Indiana Confidential Sexually Transmitted Disease Report - State Form 56459
• Influenza-Associated Deaths Case Investigation - State Form 52576 
• Influenza Lab Submission - State Form 35212
• Leptospirosis Case Investigation - State Form 52346 
• Mosquitoborne Encephalitis Case Investigation - State Form 51382 
• Perinatal Hepatitis B Case Investigation - State Form 52589 
• Pregnant Women HIV Test History and Assessment - State Form 52048 
• Refugee Health Assessment Form - State Form 53700
• Severe Staphylococcus Aureus Infection in a Previously Healthy Person Case Investigation - State Form 53653
• • Form 53653 Instructions
  • Rule Effective July 1, 2008
• TB - Contact Investigation Report - State Form 50007
• TB - Hospital Reimbursement Claim - State Form 46596
• TB - Monthly TB Follow Up Report - State Form 48092
• TB - Report of Latent Tuberculosis Infection - State Form 49894
• TB - Report of Tuberculosis - State Form 14058
• TB - Request for TB Drugs  - State Form 48085
• TB - Tuberculosis Waiver Request  - State Form 46595
• Vaccine Administration Record, State Form 54642 (05-06)
• Varicella (Chickenpox) Case Investigation - State Form 5380

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

          Review all the Clinical and Environmental

Medical Radiology

• Application for Radiology License (Not License Renewal)
• Application for Approval of Radiology Program
• Application for Proficiency Certification for Limited Radiographer
• Board Form X
• Radioactive Materials Registration Application
• Radiation Machine Registration Application
• Renew or Verify a License or Registration
  • All licensed individuals (Nuclear Medicine, Radiation Therapy and Radiologic Technologists) may renew their licenses online through the License Express online licensing system
  • Online renewal is now available for individuals that hold licenses in multiple categories (e.g. Nuclear Medicine and Radiologic Technology). Please pay for each separately. Notify our office at MedicalRadiology@isdh.IN.gov that you have renewed more than one license. We will initiate the process for refunding the appropriate fees.

 

School Screening

• Vaccine Administration Record, State Form 54642 (05-06)

Vital Records/Birth/Death Certificates

Adoption

• Record of Adoption (State Form 05438)
• Adoption Matching Program: Birth Parent Contact Preference Form - State Form 56535
• Application for Search of Medical History Information for Adoptee - State Form 47261
• Identifying Information Indiana Adoption History Registration - State Form 47896 
• Non-Identifying Information Indiana Adoption History Registration - State Form 47897 
• Indiana Adoption Medical History Report - State Form 9966 
• Indiana Adoption Medical History Registry - State Form 13342 
• Indiana Putative Father Registration (State Form 46750) Instructions
• Request for Putative Father Search and Affidavit of Search Results (State Form 54808)

Birth

• Application for Search and Certified Copy of Birth Record - State Form 49607 (R10 / 9-18) Word | PDF
  • ID Requirements
• July 1, 2010 and after - Hospital Paternity Affidavit Form - to be completed by the Hospitals/Birthing Centers only
  • Paternity Affidavit - Hospital Use (State Form 44780)
     
• July 1, 2010 and after - Local Health Department Paternity Affidavit Form - to be completed by the Local Health Department only
  • Local Health Department Paternity Affidavit – Child More than 60 Days Old 
  • Local Health Department Paternity Affidavit – Child Less than 60 Days Old
• Establishing Paternity
• Establishing Paternity Brochure
• Application for Search of Paternity Affidavit - State Form 54763
• Paternity Affidavit Upon Marriage - State Form 48468
• Accredited Labs for Paternity Genetic Testing
• Estableciendo Paternidad
• Estableciendo Paternidad Folleto

Death

• Application for Search and Certified Copy of Death Record - State Form 49606 (R8 / 9-18) Word | PDF
• Application for Permit to Disinter, Remove, and Reinter Human Remains - State Form 38697 

Indiana Clerk of Courts Documents

• Certified Court Order to Change Birth Record to Establish Paternity or Other Changes to Birth Record - State Form 47970

Marriage

• Application for Search for Certified Record of Marriage - State Form 54764 (R4 / 10-18)

Terminations

• Terminated Pregnancy
• Abortion Complication Report PDF
• Abortion Complication Report Word

Confidential User Agreements

• SF 53753 ISDH IBRS/IDRS Confidentiality Agreement
• SF 53758 IBRS/IDRS User Removal