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

Office of Drinking Water

• Permits and Design Forms

Office of Emergency Medical Services

Please see the Documents, Forms & Downloads page on the Office of Emergency Medical Services Web site.

Office of Environmental Health Services

Bedding and Upholstery Inspection

• Bedding & Upholstered Furniture Forms

Division of Food and General Environmental Services

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

Division of Sewage and Water Services

• Alternative Discharging Sewage Treatment Regulations – 12 VAC 5-640-10 et seq. : Effective Date July 30, 1992 (unavailable)
• 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 (unavailable)
• AOSE Application (unavailable)
• AOSE Renewal Application (unavailable)
• 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

Office of Epidemiology

• Morbidity Reporting Form (Epi-1, Revised 2011)

Division of Immunization

• School Requirements Forms
• Virginia Vaccines for Children
• Perinatal Hepatitis B Prevention Forms

Division of HIV, STD, and Pharmacy Services

• DDP Monthly Request for Payment Template
• Budget Reallocation Request
• Community HIV Planning Group Online Application
• HIV Testing & Screening Law
• VDH HIV Testing Quality Assurance Manual
• HIV/STD Literature Request Form
• Resource Connections

Tuberculosis

• Forms for Local Health Departments
• Screening and Testing for TB
• LTBI Resources
• TB Disease Resources
• Virginia TB Law

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

Office of Minority Health and Public Health Policy

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

Office of Human Resources

• EEO Complaint Form

Office of Licensure and Certification

• Certificate of Public Need Forms

Office of Chief Medical Examiner

• Declaration of Intent