Department of Health
John J. Dreyzehner, MD, MPH, Commissioner

• Advanced Care Plan Form (PH-4194)
• English
• Appointment of Health Care Agent Form
• English
• Español
• Appointment of Surrogate Form
• English
• Español
• Physician Order for Scope of Treatment (POST) Form (UDNR) (PH-4193)
• English

• Tennessee Breast and Cervical Cancer Early Detection Program Brochure
• Programa de Detección Temprana del Cáncer del Seno y de la Cervix de Tennessee
• You May be at Risk for Breast Cancer Bookmark
• You May be at Risk for Cervical Cancer Bookmark

• Report from November 21, 2008 Cancer in Tennessee Appalachia Roundtable Discussion
• Bylaws
• Membership Form
• 2008 Cervical Cancer Prevention Plan
• Burden of Cancer in Tennessee
• Tennessee Comprehensive Cancer Control Plan for 2009-2012
• Tennessee Cancer Registry's Annual Report: Cancer in Tennessee 1997-2003

• Printable Instructions for Applicants Living in the State of Tennessee
• Printable Instructions for Applicants Living Outside the State of Tennessee

• Public Health Assessments and Consultations
• Asbestos Facts
• Built Environment Facts
• Exposure Facts
• About Exposure Investigations
• About Health Consultations
• Mercury Facts
• Mold Facts
• About Public Health Assessments
• Radon Facts

• Folic Acid Activities: Inside/Outside
• Folic Acid Activities: Paper Charades
• Folic Acid Activities: Everybody's Watching
• Folic Acid Activities: Vocabulary Concentration (includes vocabulary words, definitions, and numbers)
• Folic Acid: A Vitamin That Could Change a Life Forever (ppt)
• Sample Script for PowerPoint Presentation

• Camp Inspection Report
• Child Care Facility Inspection Report
• Construction Requirements
• Permit Fees
• Food Review Plan
• Hotel Inspection Form
• Body Piercing Establishment Inspection Form
• Public Pool Inspection Form
• School Plant Inspection Form
• Tattoo Establishment Inspection Form

• TN Department of Health Trading Partner Agreement
• Privacy Pamphlet
• Privacy Pamphlet (Spanish)
• History of HIPAA
• HIPAA Manual
• EDI Testing
• EDI Packet Instructions
• Business Associate Agreement
• Application for Authorization
• Tennessee Department of Finance and Administration HIPAA Pamphlet
• 837P Professional Claim
• 276 Claim Status Request
• 277 Claim Status Response
• 837I Institutional Claim

• 2002 Unusual Event Summary Report
• 2003 Nursing Home Report
• 2004 Nursing Home Report
• 2005 Nursing Home Report
• 2006 Nursing Home Report
• 2007 Nursing Home Report
• Applications
• Advance Directives Forms
• Architectural & Engineering Guidelines for Submission, Approval & Inspection of Occupancies Licensed
• Assisted Care Living Facility Plans Review and Submittal Form (PH-4096)
• Critical Access Hospitals
• CMS National Provider Indentifiers (NPI) Notice
• Complaint/Investigation Intake Report
• Designated Trauma Centers
• Educational Training for Nursing Homes (ppt)
• Facility Document (Sample)
• Hospice Waiver Request Instructions
• Interpretative Guidelines for Reporting Unusual Incidents Manual - January 2005
• Quality Enabling Program Participants
• Patient Record of Influenza Vaccination Consent/Declination (pdf)
• Patient Record of Influenza Vaccination Consent/Declination (doc)
• Pediatric Emergency Care Levels
• Plans Review Submittal Form
• Procedures for Appear Before the Board for a Waiver Request
• Questions and Answers from Nursing Homes Educational Seminars (February 2008)
• Recommended Best Practices - 7 Components of Abuse Prevention
• Recommended Best Practices - Medication Errors
• Recommended Best Practices - Wrong Site Surgery
• Self-Evaluation Survey Form for Nursing Homes (PH-2714)
• Self-Evaluation Survey Form for Hospitals & Other Facilities
• Self-Evaluation Guide for Section 504
• Sprinkler Status Reports: Nursing Homes
• Sprinkler Status Reports: Assisted Care Living Facilities
• Sprinkler Status Reports: Homes for the Aged
• Toll-Free Hotline Numbers Example Sign
• Training for Nursing Home Staff and Administrators
• Under 55 Residential Home for the Aged (RHA) or
  Under 62 Assisted Care Living Facility (ACLF) Waiver Application (PH-4195)
• Unusual Events Reporting Form Letter
• Unusual Event Report(Sample Form)
• Unusual Incident Report Form (PH-3688)
• Unusual Incident Medication Error Report Form) (PH-3689
• Unusual Incident Investigative Analysis Form (PH-3687)

Fact Sheets

• Coronary Heart Disease
• High Cholesterol
• Diabetes
• Fruit and Vegetable Consumption
• High Blood Pressure
• Overweight and Obesity
• Physical Activity
• Smoking
• Stroke
• Symptoms of Heart Attack and Stroke

Burden Documents

• The Burden of Heart Disease and Stroke in Tennessee 2006 Report
• The Burden of Heart Disease and Stroke in Tennessee 2006 Technical Report
• The Burden of Heart Disease and Stroke Special 2007 Update Report

State Plan

• The Tennessee Heart Disease and Stroke Prevention and Care Plan

Other Documents

• Heart Disease and Stroke Program Partner Form
• GiveMe5 for Stroke: Warning Signs

• Improving Patient Safety Coalition Members
• Health Data Reporting Act of 2002 #68-11-211 (PDF)
• Click here to view the "Interpretative Guidelines for Reporting Unusual Incidents Manual
• 2003-2007 Quarterly Reports
• 2002 Unusual Event Summary Report
• 2003 Unusual Event Summary Report
• 2004 Annual Patient Safety Report
• 2005 Annual Patient Safety Report
• Seven Components of Abuse Prevention
• Wrong Site Surgery
• Medication Errors (10 Confusing Abbreviations to Avoid)
• Medication Errors (15 Ways to Lower your Dose of Medication Errors)
• Effective and Underused Safety Practices
• Falls Tool Kit
• Ensuring Correct Surgery
• Choking
• Universal Medication List Form Introduction
• Universal Medication List Form - English
• Universal Medication List Form - Spanish
• 20 Tips to Help Prevent Medical Errors
• 20 Tips to Help Prevent Medical Errors in Children
• Nursing Home Compare Surveys

• Got a question about your pregnancy?: Ask a Nurse
• Caring for Your Baby
• Chronic Disease: Women Create Their Own Paths to Health
• Pregnant? Dont Forget to Take Good Care of Your Teeth!
• Infant Mortality Display Toolkit
• Domestic Abuse During Pregnancy
• Exercise: Why get fit?
• Feeding Your Baby
• The First Trimester
• The Who, What, Where, and Why of Folic Acid
• Getting Ready for Your Baby
• Handling Stress
• Healthy Behaviors
• Healthy Relationships
• Infant Mortality Trends: Tennessee and the US (1994 - 2004 )
• What Do Infant Mortality Statistics Tell Us?
• Ranked cause of death in the neonatal and post-neonatal periods Tennessee (1999 - 2004)
• Immunizations
• Infant Mortality - Shelby County Tennessee
• Key Definitions
• Things you Need to Know About Taking Care of Yourself After Your Baby is Born
• Preconception Care: 12 Things to Do Before You Become Pregnant
• Quitline Offers Help for Tobacco Users
• Reproductive Health
• The Second Trimester
• Feeling Good About Yourself
• When Your Baby is Sick
• Infant Moratlity in Tennessee
• The Third Trimester
• Infant Morality Tennessee Residents 1999 - 2004
• Youth Nutrition

• Interscholastic Sports Examination Form

• Directory of Services
• CLIA Certificates and Laboratory License
• Newsletters

• MRSA Fact Sheet
• Toolkit for Athletic Director and Coaches
• Toolkit for School Health Officials
• Toolkit for School Custodians
• Methicillin-Resistant Staphylococcus Aureus (MRSA) Infections Report and Recommendations of the Tennessee Department of Health Infections Taskforce January 2008
• nvasive Methicillin-Resistant Staphylocccus Aureus (MRSA) Reporting in Tennessee 2008

• Standards for Practice Manual for Dental Public Health

• State Conrad J-1 Visa Waiver Program Policies and Procedures
• J-1 Visa Waiver Program Policies and Procedures
• Health Access Plan
• Printable Shortage Area Maps

• TBI Patients Treated in TN and Discharged in 2009 Statewide Profile
• Traumatic Brain Injury Annual Report 2011-2012
• Traumatic Brain Injury Services Directory and Resource Guide
• Service Coordinators
• Brain Injury Support Groups
• TBI Registry Newsletter
• TBI Newsletter (TBI Headlines)

• Tennessee Perinatal Care System, Guidelines for Regionalization Hospital Care Levels, Staffing and Facilities
• Tennessee Perinatal Care System Guidelines for Transportation
• Tennessee Perinatal Care System - Educational Objectives for Nurses, Levels I, II, III, Neonatal Transport Nurses
• Educational Objectives in Medicine for Perinatal Social Workers