| AIDS |
|
AIDS Drug
Assistance Program Application
| Adoption |
|
Adopted Person Registration
Forms
Adoptive Parent Registration
Forms
Biological Father
Affidavit
Biological Mother Affidavit
Birth Parent Registration
Forms
Legal Guardian Registration
Forms
Non-Surrendered Birth Sibling
Registration Forms
Surrendered Person Registration
Forms
| Ambulatory Surgical Treatment Centers |
|
Ambulatory Surgical
Treatment Center Initial Licensure - Fillable PDF*
Ambulatory
Surgical Treatment Center Medicare Certification - PDF
Ambulatory
Surgical Treatment Center Project Submission Form - Fillable PDF*
Ambulatory
Surgical Treatment Center Renewal Licensure - Fillable PDF*
Facility Information Change Form - Fillable PDF*
Construction Award Form - PDF
Certifications for Request for Inspection - Fillable PDF*
Occupancy Matrices
Matrix 4A - UL Assembly Ratings - Fillable PDF*
Matrix 4B - Through Wall/Floor Penetrations - Fillable PDF*
Matrix 4C - Interior Finishes - Fillable PDF*
Matrix 4D - Project Cost and Fee Verification - Fillable PDF*
Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF*
Matrix 4F - Air Balancing - Fillable PDF*
Temporary Occupancy Policy - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Animal Population Control Program |
|
Application/Eligibility Voucher for Low-Cost Spay/Neuter - Fillable PDF*
Veterinarian Application/Agreement to Participate - Fillable PDF*
| Asbestos |
|
Asbestos Abatement Notification Form - Fillable PDF*
Asbestos Contractor Application
- Fillable PDF*
Asbestos Professional Application
- PDF - Instructions
Abestos in Schools, Responsibilities of
Local Education Agencies for
Asbestos Training Courses, List of Illinois
Accredited - PDF
Asbestos Training Course Instructor Application - PDF
Asbestos Training Course Provider
Application - PDF -
Instructions
Asbestos Worker Application
- Fillable PDF*
LEA Responcibilities Under AHERA - Fillable PDF*
Project Manager's Report Form - Fillable PDF*
Request for Variance Cover Sheet - Fillable PDF*
| Assisted Living/Shared Housing Establishments |
|
Assisted Living/Shared Housing Initial License Application
Involuntary Termination of Residency Forms
Residency Involuntary Termination Form - PDF
Appeal Hearing Request Form - PDF
| Birthing Centers |
|
Birthing Center Initial Licensure Application - Fillable PDF*
| Campgrounds and Recreational Areas |
|
Application for Original Campground License - PDF
Application for Campground Construction Permit - PDF
Injury and Illness Report - PDF
Special Flood Hazard Area Location Request Form - PDF
| Child Health Examination Form |
|
Certificate of Child Health Examination Form - PDF
| Childhood Lead Poisoning |
|
Now listed under Lead
| Clinical Laboratory Improvement Amendment |
|
CLIA Certification Address Change Form - PDF
CLIA Certification Director Change Form - PDF
CLIA Certification Name Change Form - PDF
CLIA Certification Renewal Request Form - PDF
CLIA Change of Ownership Form - PDF
CLIA Instruction Sheet for Tables - PDF
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Comprehensive Outpatient Rehab
Facilities |
|
Comprehensive
Outpatient Rehab Facility Medicare Certification - PDF
Facility
Information Change Form - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Dental Exams, School |
|
Dental Examination Form, Proof of School - PDF En Español - PDF
Dental Examination Waiver Form - PDF En Español - PDF
| Discharge Request for Hearing, Involuntary Transfer or |
|
Notice of Involuntary Transfer or Discharge and Opportunity for Hearing Form - En Español - Fillable PDF*
Involuntary Transfer or Discharge Request for Hearing Form - En Español - Fillable PDF*
| Emergency Medical Services |
|
Emergency Department Approved for Pediatrics (EDAP) Nurse Practitioner Waiver - Fillable PDF
Emergency Department Approved for Pediatrics (EDAP) Physician Waiver - Fillable PDF
Emergency Medical Systems Extension Application - PDF
Emergency Medical Systems
Inactive/Reactivation Application - PDF
Emergency Medical Technician (EMT) Examination
Emergency Medical Technician (EMT) Reciprocity Application - Fillable PDF
EMS System Application Instruction Guide
Independent EMS License Renewal Request Form - PDF
Reasonable Accommodation Request for Examinees with Disabilities - Fillable PDF
Renewal Notice - PDF
Trauma Nurse Specialist (TNS) Examination Application
| End Stage Renal Dialysis Facilities |
|
End Stage Renal
Dialysis Medicare Certification - PDF
Facility Information Change Form - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| End Stage Renal Dialysis Facilities |
|
End Stage Renal Dialysis Medicare Certification - PDF
| Eye Examination |
|
Listed under Vision
| Food Service Sanitation Manager
Certification |
|
FSSMC Request Form
- PDF
| Free Sale, Certificate of |
|
Request for Certificate of Free Sale - form and preparation guidelines - Fillable PDF*
Sample Letters - Word
| Freedom of Information Act |
|
Freedom of Information Act Form - Fillable PDF*
| Freestanding Emergency Centers |
|
Certifications for Request for Inspection - Fillable PDF
Occupancy Matrices
Matrix 4A - UL Assembly Ratings - Fillable PDF*
Matrix 4B - Through Wall/Floor Penetrations - Fillable PDF*
Matrix 4C - Interior Finishes - Fillable PDF*
Matrix 4D - Project Cost and Fee Verification - Fillable PDF*
Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF*
Matrix 4F - Air Balancing - Fillable PDF*
Freestanding Emergency Center (FEC) Initial Licensure Application - Fillable PDF
Freestanding Emergency Center (FEC) Renewal Licensure Application - Fillable PDF
Project Submission Form for Freestanding Emergency Center - Fillable PDF
*These are draft forms pending final approval of the rules.
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Health Care Worker |
|
Foreign Nurse Application - PDF
Military Personnel Application - PDF
Nursing Student Application - PDF
Out of State CNA Application - PDF
UCIA Background Check Form
Waiver Application - PDF
Waiver Application -Facts - PDF
| Health Facilities Planning
Board |
|
Health
Facilities Planning Board - Application for Exemption — Change of
Ownership for an Existing Health Care Facility
Health Facilities Planning Board -
Application for Exemption from Certificate of Need Review and Permit
Requirements
Health Facilities Planning Board - Application
for Permit - PDF
| Health Examination Form, Child |
|
Certificate of Child Health Examination Form - PDF
| Hearing Forms |
|
Audiogram Form
- PDF
Hearing Conservation Annual
Report - PDF
Hearing Instrument
Complaint Form - PDF
Hearing
Instrument Dispenser Inactive Status Request Form - PDF
Hearing
Instrument Dispenser License Application Form - PDF
Hearing
Instrument Dispenser License Correction Form - PDF
| Home Health, Home Services, Home Nursing, Placement Agency |
|
[New Combined Home Health, Home Services, Home Nursing and Placement Agency Initial Application is now available.]
Home Health, Home Services, Home Nursing and Placement
Agency Licensing Initial Application - Fillable PDF*
Home Health, Home Services, Home Nursing and Placement
Agency Licensing Renewal/Change of Ownership Application - Fillable PDF*
Home Health
Agency Medicare Certification - PDF
Home
Health Agency Administrative Staff Changes - PDF
Home Health Agency Management Status Form - Fillable PDF*
Home
Health Agency - Hospice Add or Remove Geographic Service Areas - PDF
Home Health
Agency Add or Removes Services - PDF
Home Health
Agency Branch Questionnaire - Fillable PDF*
Facility Information Change Form - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Hospice |
|
Hospice
Application Licensure - Fillable PDF*
Hospice Renewal
Licensure - PDF
Hospice Administrative Staff Changes - PDF
Hospice
Medicare Certification - PDF
Hospice Change
of Ownership - PDF
Facility Information Change Form - Fillable PDF*
Home
Health Agency - Hospice Add or Remove Geographic Service Areas - PDF
Multiple Hospice Location Questionnaire - PDF
Hospice Residence Initial/Renewal Application - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Hospital |
|
Hospital Initial Licensure - Fillable PDF*
Hospital Medicare Certification - PDF
Facility Information Change Form - Fillable PDF*
Hospital Project Submission Form - Fillable PDF*
Construction Award Form - PDF
Certifications for Request for Inspection - Fillable PDF
Occupancy Matrices
Matrix 4A - UL Assembly Ratings - Fillable PDF*
Matrix 4B - Through Wall/Floor Penetrations - Fillable PDF*
Matrix 4C - Interior Finishes - Fillable PDF*
Matrix 4D - Project Cost and Fee Verification - Fillable PDF*
Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF*
Matrix 4F - Air Balancing - Fillable PDF*
Temporary Occupancy Policy - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Integrated Pest Management |
|
Licensed Day Care Centers Form - Fillable PDF*
Public Schools Form - Fillable PDF*
| Involuntary Transfer or Discharge Request for Hearing |
|
Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form
- En Español - Fillable PDF*
Involuntary Transfer or Discharge Request for Hearing Form - En Español - Fillable PDF*
| Irrigation |
|
Irrigation Contractor, Application for Registration for - PDF
Irrigation Contractor's Test Certificate Lawn - PDF
Irrigation Contractor Application Child Support Certification - PDF
Irrigation Employee, Notice of Cancellation of Employment Registered - PDF
Irrigation Employee, Application for Registration for - PDF
Irrigation/Sprinkler System
Lawn Sprinkler System, Contractor's Test Certificate - PDF
| Laboratories |
|
Communicable Diseases Laboratory Test Requisition - PDF
Rabies Submission Form - PDF
Request for Respiratory/Influenza Testing - PDF
Service Improvement Form - Fillable PDF
STD/HIV Test Requisition Form - PDF
Test Request for Blood Lead Analysis - PDF Instructions
| Lead |
|
Lead Abatement/Mitigation Project, Notice of Commencement - PDF
Lead Assessment Form, Public Health Nurse Home - PDF
Lead Program Contact Record and Order Form - PDF
Lead
Contractor Application - PDF -
Instructions
Lead Contractor 7-day Notice
Form - PDF
Lead Contractor Application
Checklist - PDF
Lead License Renewal Application - PDF
Lead Program Publications Order Form - Fillable PDF
Lead Public Information Disclosure
Form - PDF
Lead Risk Assessment Questionnaire and Guidelines, Childhood - En Español -
En français - PDF
Lead Risk Assessment Questionnaire, Medical Childhood - Excel (Longitudinal record for physician office use)
Lead Supervisor, Inspector, Risk
Assessor, Application - PDF - Instructions
Lead Third Party Examination
Application - PDF
Lead Training Course Application - PDF - Instructions
Lead Training Course Notification Form - PDF
Lead Training Course Roster - PDF
Lead Worker Application or En Español - PDF - Instructions
Pediatric Lead Poisoning High-Risk ZIP Code Areas - En Español - PDF
Report of Blood Lead Test Result - Filliable PDF
| Long-Term Care |
|
Certifications for Request for Inspection - Fillable PDF
Occupancy Matrices
Matrix 4A - UL Assembly Ratings - Fillable PDF*
Matrix 4B - Through Wall/Floor Penetrations - Fillable PDF*
Matrix 4C - Interior Finishes - Fillable PDF*
Matrix 4D - Project Cost and Fee Verification - Fillable PDF*
Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF*
Matrix 4F - Air Balancing - Fillable PDF*
Temporary Occupancy Policy - Fillable PDF*
Notification of Construction Start Date
- PDF
Non-flammable Medical Gas Storage and Mechanical
System Requirements - PDF
Nursing Home Licensure – Administrator Form – Fillable PDF
Nursing Home Licensure – Alzheimer’s Special Care – Fillable PDF
Nursing Home Licensure – Application – Fillable PDF
Nursing Home Licensure – Budgeted Financial Statement – Excel
Nursing Home Licensure – Capacity & Level of Care – Fillable PDF
Nursing Home Licensure – Licensure Information - PDF
Nursing Home Licensure – Personal Data Sheet – Fillable PDF
Nursing Home Licensure – Surety Bond - PDF
Project Submission Form -
PDF
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Manufactured and Modular Homes/Mobile Structures |
|
Application for Manufactured Home Community (a/k/a Mobile Home Parks)
Manufactured Home Community Transfer Application
Original Application for Manufactured Home Installer License
Renewal Application for Manufactured Home Installer License
Application for Manufactured Home Manufacturer License
Request for Manufactured Home Installation Seals and Certificates
Manufactured Housing Consumer Complaint Form
| Medicare Intermediary |
|
Medicare Intermediary Information Form - Fillable PDF*
| Migrant Labor Camps |
|
Migrant Labor Camp Original/Renewal License Application - PDF
| Non-Community Public Water System |
|
Non-Community Public Water System Construction Application - PDF
| Nursing Home Licensure |
|
See Long-Term Care
Outpatient Physical Therapy/Speech Pathology/
Occupational Therapy Services |
|
OPT-SP-OTS
Facility Medicare Certification - PDF
Facility Information Change Form - Fillable PDF*
| Plumbing |
|
Application for Registration of Continuing Education - PDF
Code Book Order Form - PDF
Electronic Roster for Plumbers Continuing Education
Plumber Application Child Support Certification - PDF
Plumber's
Apprenticeship Application Under JAC- PDF
Plumber's License
Application, Apprentice - PDF
Plumber's
License, Application for Examination for - PDF
Plumber's License,
Application for Restoration of Expired - PDF
Plumber's License,
Application for Retired - PDF
Plumber's License
Reciprocity with the City of Chicago, Application for -
PDF
Plumber's Retake Examination Form - PDF
Plumbing Inspectors, Application for Examination for Certification of - PDF
Plumbing License Online Renewals
Plumbing Notice of
Cancellation of Employment/Supervision of Apprentice-
PDF
| Plumbing Contractor |
|
Affidavit of No Employees - PDF
Plumber Application Child Support Certification - PDF
Plumbing Contractor Application for Registration or Renewal - PDF
Plumbing Contractor Registration Online Renewals
Plumbing Contractor Surety Bond Forms
- Corporation - PDF
- Limited Liability Company - PDF
- Partnership - PDF
- Sole Proprietor - PDF
Worker’s Compensation Opt-Out Form - PDF
| Portable X-ray Facilities
|
|
Portable X-ray Medicare Certification - PDF
Facility Information Change Form - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Pregnancy Termination Facility |
|
Pregnancy Termination Initial Licensure - Fillable PDF*
Pregnancy Termination Renewal Licensure - Fillable PDF*
Facility Information Change Form - Fillable PDF*
| Rural Health Centers |
|
Rural Health Medicare Certification - PDF
Facility Information Change Form - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)
| Scholarship Opportunities
|
|
Allied Health Care Professional
Scholarship Program Application - PDF
Medical Student Scholarship
Program Application - PDF
Nursing Education
Scholarship Program Application - PDF
| School Physical |
|
School Physical -- Certificate of Child Health Examination Form
| Structual Pest Control |
|
Integrated Pest Management Forms (See Integrated Pest Management)
Explanation of Technician Examinations - PDF
Structural Pest Control: Business application, Non-Commercial - PDF
Structural Pest Control: Business License
application, Commercial - PDF -
Instructions
Structural Pest Control Certificate of
Insurance - PDF
Structural Pest Control Technician
Application (General Use) - PDF -
Instructions
Structural Pest Control Technician
Application (Restricted Use) - PDF -
Instructions
Structural Pest Control Technician
Re-examination application - PDF - Instructions
| Surrogate Parentage |
|
Attorney's Certification Form - PDF
Gestational Surrogate Form - PDF
Gestational Surrogate's Husband - PDF
Intended Father Form - PDF
Intended Mother Form - PDF
Physician's Statement Form - PDF
| Swimming Pools |
|
Drowning Injury Illness Report - PDF
Special Flood Hazard Area Location Request Form - PDF
Swimming Facility Construction Permit, Application for - PDF
Swimming Facility License, Application for - PDF
Swimming and Beach Facility Online Renewal
Trauma Nurse Specialist (TNS) Examination Application - Fillable PDF
Trauma Nurse Specialist (TNS) Application Instruction Guide
Trauma Nurse Specialist Course Coordinators (TNSCC) Testing Application Submission
Trauma Nurse Specialist (TNS) Examination Roster - PDF (Word)
| Vision |
|
Eye Examination Report 2009 - PDF
Eye Examination Waiver Form 2009 - PDF
Vision Conservation Annual
Report - PDF
Vision Examination Report (V-4) -
PDF
Vision Screening Worksheet -
PDF
Vision Rescreening Worksheet -
PDF
| Vital Records |
|
Adopted Person Registration
Forms
Adoptive Parent Registration
Forms
Biological Father Affidavit - PDF
Biological Mother Affidavit - PDF
Birth Parent Registration Forms
Birth Record
Files, Application for Search of - PDF
Birth Record Files of a Deceased Individual, Application for Search of - PDF
Birth Record Files of a Deceased Infant, Application for Search of - Fillable PDF*
Correction of a Birth Certificate, Application for - PDF
Correction of a Death Certificate, Application for - PDF
Death Record
Files, Application for Search of - PDF
Divorce
Record Files, Application for Verification of - PDF
Legal Guardian Registration
Forms
Marriage Record Files, Application for Verification of - PDF
Non-Surrendered Birth Sibling
Registration Forms
Attorney's Certification Form - PDF
Gestational Surrogate Form - PDF
Gestational Surrogate's Husband - PDF
Intended Father Form - PDF
Intended Mother Form - PDF
Physician's Statement Form - PDF
| Water Wells |
|
Water Well, Application for Permit to Construct, Modify or Abandon a - Fillable PDF*
Water Well Construction Report - Fillable PDF*
Water Well Construction Report Instructions - PDF
Water Well Contractor Online Renewal
Water Well Pumps, Installation Report for - Fillable PDF*
Water Well Sealing Form - Fillable PDF*
| Youth Camps |
|
Application for Original Youth Camp License - PDF
Application for Youth Camp Construction Permit - PDF
Injury and Illness Report - PDF
|
