Forms

FORMS

Clinic Forms

English

• Master Sheet

• Patient Authorization

• Release of Information

• HIPAA Notice of Privacy Practices

• Authorization to Consent to Health Care for Minor

• Medical Examination Report Form (for Commercial Driver Medical Certification)

• 2024-2025 Flu Form

en Español

• Hoja Principal

• Autorizacion de Paciente

• Permiso Para Usar y Divulgar Information de Salud del Paciente

• HIPAA Aviso de Practicas de Privacidad

• Autorizacion para dar Consentimiento a la Atencion Medica para Menores

• 2024-2025 La Influenza

Laboratory Forms for contract lab services

• Nitrate/Nitrite Analysis Form

• Bacteriological Analysis Form

WIC/Nutrition Forms

• Referral to Jackson County Department of Public Health for MNT

• Referral to Jackson County Department of Public Health for Diabetes

Environmental Health Forms

Animal Shelter Forms

• Animal Shelter Record Request Form

Food, Lodging, and Institutions Forms

• Advanced Notification for a Seasonal Operation pdf; Advanced Notification for a Seasonal Operation fillable

• Application for a Child Care Center

• Application for a Lodging Permit

• Existing/Change in Ownership Food Establishment Plan Review Application pdf; Existing/Change in Ownership Food Establishment Plan Review Application fillable

• Food Establishment Plan Review Application pdf; Food Establishment Plan Review Application fillable

• Limited Food Service Establishment (LFSE) Permit Application pdf; Limited Food Service Establishment (LFSE) Permit Application fillable

• Plan Review Application for Food Establishments Operating from a Shared Use Kitchen

• Plan Review Checklist

• Request for a Variance

• Temporary Food Establishment Vendor Application pdf; Temporary Food Establishment Vendor Application fillable

• Temporary Food Event Commissary Application pdf; Temporary Food Event Commissary Application fillable

Onsite Waste Water Protection (Septic System) Forms

To review the steps required to make a septic or well application, click here.  Onsite and Well Permit Information Forms:

• Application for Environmental Health Services

• Environmental Health General Information

• Wastewater and Well Application Checklist

• Example Site Plan

• Record Search for Septic or Well Records

• Private Well Water Test Requests

• Environmental Health Fees

Other Forms

• Public Swimming Pool Pre-Permitting Checklist

• Application for Public Swimming Pool Operation Permit

• Application to Construct, Install, Remodel, or Modify a Public Swimming Pool

• Application for Tattooing Permit

BROCHURES

• JCDPH Brochure

• En Español

• Clinic Services

• En Español

• Nutrition Services at Jackson County Health Department