Indiana State Department of Health
Forms
- Communicable Disease
- Fireworks Injury Reporting
- HIPAA
- 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 (R3/4-04)
- Babesiosis Case Investigation - State Form 52135 (5-05)
- Blood or Body Fluid Exposure, Notification of - State Form 51467 (11-11)
- Confidential Report of Communicable Diseases - State Form 43823 (R2/11-96)
- Hepatitis B and Delta Hepatitis Case Investigation - State Form 52587 (R/11-09)
- Hepatitis C Case Investigation - State Form 52588 (R/11-09)
- Histoplasmosis Case Investigation - State Form 52253 (7-05)
- Influenza-Associated Deaths Case Investigation - State Form 52576 (2-06)
- Influenza Lab Submission - State Form 35212
- Legionellosis Case Investigation - State Form 49817 (R2/5-05)
- Leptospirosis Case Investigation - State Form 52346 (8-05)
- Mosquitoborne Encephalitis Case Investigation - State Form 51382 (R/4-04)
- Perinatal Hepatitis B Case Investigation - State Form 52589 (2-06)
- Pregnant Women HIV Test History and Assessment - State Form 52048 (R/3-11)
- Refugee Health Assessment Form - State Form 53700
- Severe Staphylococcus Aureus Infection in a Previously Healthy Person Case Investigation - State Form 53653
- 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 Treatment of Latent TB 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 53800
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) 233-7761; Attn: Injury Epidemiologist
Or mail to: Indiana State Department of Health
2 North Meridian Street, 2 Selig
Indianapolis, IN 46204
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
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
Vital Records/Birth/Death Certificates
Adoption
- Adoption History Registration Program Birth Parent Nonrelease Form (State Form 46392)
- Application for Search of Medical History Information for Adoptee - State Form 47261
- 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)
- Indiana Adoption Medical History Registry - State Form 13342 (R3 / 9-08)
- Record of Adoption (State Form 05438)
- 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 (R3 / 10-07)
- July 1, 2010 and after - Hospital Paternity Affidavit Form - to be completed by the Hospitals/Birthing Centers only
- July 1, 2010 and after - Local Health Department Paternity Affidavit Form - to be completed by the Local Health Department only
- 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 (R4 / 9-11)
- Application for Permit to Disinter, Remove an Reinter Human Remains - State Form 38697 (R3/12-07)
Indiana Clerk of Courts Documents
Marriage
- Application for Marriage License -State Form 53394
- Application for Search of Marriage Index - State Form 54764
- For Clerk of Courts Use Only
Terminations
Confidential User Agreements
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