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Rod R. Blagojevich, Governor; Eric E. Whitaker, M.D., M.P.H., Director

 

FORMS

Z Y X W V U T S R Q P O N M L K J I H G F E D C B A

 
   AIDS Top of Page

AIDS Drug Assistance Program Application

   Adoption Top of Page

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 Top of Page

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 Top of Page

Application/Eligibility Voucher for Low-Cost Spay/Neuter - Fillable PDF*

Veterinarian Application/Agreement to Participate - Fillable PDF*

  Asbestos Top of Page

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 Top of Page

Assisted Living/Shared Housing Initial License Application
Involuntary Termination of Residency Forms
    Residency Involuntary Termination Form - PDF
    Appeal Hearing Request Form - PDF

  Birthing Centers Top of Page

Birthing Center Initial Licensure Application - Fillable PDF*

  Campgrounds and Recreational Areas Top of Page

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 Top of Page

Certificate of Child Health Examination Form - PDF

  Childhood Lead Poisoning Top of Page

Now listed under Lead

  Clinical Laboratory Improvement Amendment Top of Page

Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)

  Comprehensive Outpatient Rehab Facilities Top of Page

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

Top of Page

Dental Examination Form, Proof of School - PDF   En Español - PDF
Dental Examination Waiver Form - PDF   En Español - PDF

Discharge and Opportunity for Hearing for Nursing Home Residents, Notice of Involuntary Transfer or

Top of Page

Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form - En Español - Fillable PDF*

Emergency Medical Services

Top of Page

Alternate Rural Staffing and Response Authorization Request - Fillable PDF
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 Top of Page

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 Top of Page

End Stage Renal Dialysis Medicare Certification - PDF

  Eye Examination Top of Page

Listed under Vision

  Food Service Sanitation Manager Certification Top of Page

FSSMC Request Form - PDF

  Free Sale, Certificate of Top of Page

Request for Certificate of Free Sale - form and preparation guidelines - Fillable PDF*
Sample Letters - Word

  Freedom of Information Act Top of Page

Freedom of Information Act Form - Fillable PDF*

  Freestanding Emergency Centers Top of Page

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 Top of Page

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 Top of Page

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 Top of Page

Certificate of Child Health Examination Form - PDF

  Hearing Forms Top of Page

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 Top of Page

[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 Top of Page

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 Top of Page

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 Top of Page

Licensed Day Care Centers Form - Fillable PDF*
Public Schools Form - Fillable PDF*

Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, Notice of

Top of Page

Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form - En Español - Fillable PDF*

  Irrigation Top of Page

Irrigation Contractor, Application for Registration for - PDF
Contractor's Test Certificate Lawn Sprinkler System - PDF
Irrigation Contractor Application Child Support Certification - PDF
Irrigation Employee, Notice of Cancellation of Employment Registered - PDF
Irrigation Employee, Application for Registration for - PDF
Lawn Sprinkler System, Contractor's Test Certificate - PDF

  Laboratories Top of Page

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 Top of Page

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 Top of Page

Certifications for Request for Inspection - Fillable PDF

Occupancy Matrices

Temporary Occupancy Policy - Fillable PDF*

Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)

  Manufactured and Modular Homes/Mobile Structures Top of Page

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 Top of Page

Medicare Intermediary Information Form - Fillable PDF*

  Migrant Labor Camps Top of Page

Migrant Labor Camp Original/Renewal License Application - PDF

  Non-Community Public Water System Top of Page

Non-Community Public Water System Construction Application - PDF

  Nursing Home Licensure Top of Page

See Long-Term Care

  Outpatient Physical Therapy/Speech Pathology/
  Occupational Therapy Services
Top of Page

OPT-SP-OTS Facility Medicare Certification - PDF
Facility Information Change Form - Fillable PDF*

  Plumbing Top of Page

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 Top of Page

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 Top of Page

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 Top of Page

Pregnancy Termination Initial Licensure - Fillable PDF*
Pregnancy Termination Renewal Licensure - Fillable PDF*
Facility Information Change Form - Fillable PDF*

  Rural Health Centers Top of Page

Rural Health Medicare Certification - PDF
Facility Information Change Form - Fillable PDF*

Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields)

  Scholarship Opportunities Top of Page

Allied Health Care Professional Scholarship Program Application - PDF
Medical Student Scholarship Program Application - PDF
Nursing Education Scholarship Program Application - PDF

  School Physical Top of Page

School Physical -- Certificate of Child Health Examination Form

  Structual Pest Control Top of Page

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 Top of Page

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 and Spas Top of Page
  Trauma Top of Page

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 Top of Page

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 Top of Page

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 Top of Page

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*
Closed Loop Wells

  Youth Camps Top of Page

Application for Original Youth Camp License - PDF
Application for Youth Camp Construction Permit - PDF
Injury and Illness Report - PDF

 
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