Department of Health
John J. Dreyzehner, MD, MPH, Commissioner
Documents and Forms
Documents by Program
A-B
Advanced Directives
C-D
Comprehensive Cancer Control
- 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
E-F
Environmental Epidemiology
Folic Acid
- 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
G-H
General Environmental Health
Health Care Facilities
- 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 (PH-2714) for Nursing Homes
- 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
- 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)
Heart Disease
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
Other Documents
HIPAA
- 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
Health Professional Boards
- Athletic Trainers
- Acupuncture
- Alcohol and Drug Abuse Counselors
- Chiropractic Examiners
- Clinical Perfusionist
- Communications Disorders/Sciences
- Dentistry
- Dietitians/Nutritionist Examiners
- Dispensing Optitians
- Electrolysis Examiners
- Hearing Instruments Specialist
- Massage
- Medical Examiners
- Medical Laboratories
- Midwifery
- Nursing
- Nursing Home Administrators
- Occupational Therapy
- Optometry
- Osteopathic Examiners
- Pharmacy
- Physical Therapy
- Physician Assistants
- Podiatric Medical Examiners
- Professional Counselors and Marital and Family Therapist
- Psychology
- Respiratory Care
- Reflexology
- Social Work
- Veterinary Medical Examiners
- X-Ray Operators
I-L
Improving Patient Safety
- 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
Infant Mortality
- 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
M
Maternal and Child Health
- Child Fatalities in Tennessee 2006
- Child Fatalities in Tennessee 2005
- Child Fatalities in Tennessee 2004
- Child Fatalities in Tennessee 2003
- Child Fatalities in Tennessee 2002
- Child Fatalities in Tennessee 2001
- Child Fatalities in Tennessee 2000
- Child Fatalities in Tennessee 1999
- Tennessee Child Fatality Districts
- Tennessee Child Fatality Reveiw Districts
- Healthy Nutrition for Youth
- Physical Activity for Youth
- Positive Youth Development
- Preventing Unintended Pregnancy Among Youth
- Supporting Your Adolescent: Tips for Parents
- Talking and Listening to Youth
- Talking with Tweens About Violence
- Talking with Youth About Abstinence
- Talking with Youth About Alcohol and Drugs
- Talking with Youth About HIV and Aids
- Talking with Youth About Sex and Relationships
- Tune In for Healthy Youth
- When Your Adolescent Is In Trouble
- When Your Adolescent Needs Help
- 2008 Adolescent and Young Adult health in Tennessee Report
- Fostering Healthy Adolescents and Young Adults
- Health Disparities Among Youth and Young Adults
- Healthy Diets and Physically Fit Youth
- Healthy Sexual Development
- Healthy Teeth and Gums
- Mentally Healthy Youth and Young Adults
- Preventing Intentional Injury: From Bullying to Homicide
- Preventing Unintentional Injury: Keeping Our Youth Safe
- Substance-Free Youth and Young Adults
- Supporting Vulnerable Youth and Young Adults
- Tennessee Healthy Youth and Young Adult Priorities
- Tobacco-Free Youth and Young Adults
- Youth Access to Health Care
MRSA
- 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
Minority Health and health Disparities Elimination
- Title VI of the Civil Rights Act of 1964 Discrimination Complaint Form
- HIV/AIDS Resource Directory
- Power in the Pews Leadership Guide
- Walk and Talk Ministry Program
- Search Your Heart Training Packet
- Health Leader "Rate Your Energy Quiz"
- Congregational Health Ministry Survey
- Evaluation of Program Satisfaction Survey
N-R
Newborn Screening
- County/City Hospital Codes in Tennessee
- Tennessee 2 Digit County Code List
- Weight Conversion Chart
- Hospital Unsatisfactory Reports
Nursing Homes
See Health Care Facilities
S-T
Sexually Transmitted Diseases
- 2005 HIV Epidemiological Profile
- Tennessee Pregnancy Act of 1997 (pdf)
- PH-3273
Adult HIV/AIDS Confidential Case Report - PH-3274
Pediatric HIV/AIDS Confidential Case Report - PH-3302
Report of Positive Tests for HIV - PH-1600
Notifiable Disease Case Report for Hospitals, Physicians, Laboratories (excluding AIDS, HIV)
This form may also be acquired from the local/county health departments and regional health offices. Please note that Form PH-1600 may be copied using any copy machine. - HIV Maps
- Waived Test Notification form PH-3653
- Tennessee Department of health OraQuick Designees List
- Lead Agent List
- Request for Grant Proposal process
- Patient Delivered Therapy: An Additional Means for Addressing the Chlamydia Trachomatis Problem
- An Overview of HIV Disease in Tennessee through 1999
- What is Chlamydia?
- Azithromycin Fact and Instruction Sheet
- Chlamydia and your Baby
- Doxycycline Fact and Instruction Sheet
- ¿Que es Chlamydia?
- Hoja de los hechos y de instrucción de Azithromycin
- Chlamydia y su Bebé
- Hoja de los hechos y de instrucción de Doxycycline
- Tennessee Laws Relating to Sexually Transmitted Diseases
- STD-MIS Technical Materials
- STD Data Surveillance Reports
Tennessee Cancer Registry
Traumatic Brain Injury Program
- TBI Patients Treated in TN and Discharged in 2009 Statewide Profile
- Traumatic Brain Injury Annual Report 2008-2009
- Traumatic Brain Injury Services Directory and Resource Guide
- Service Coordinators
- Brain Injury Support Groups
- TBI Registry Newsletter
- TBI Newsletter (TBI Headlines)
- Bike Safety Poster Contest Entry Form
W-Z
Women's Health
- 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
WIC
Vital Records
- English Applications and Downloads
- Application for a Certified Copy of a Certificate of Birth (PH-1654)
- Application for Verification of Birth Facts (PH-3061)
- Notification of Order of Parentage and Application for a New Birth Certificate (PH-3343)
- Application for New Certificate of Birth by Subsequent Marriage of Parents (PH-1673)
- Application for a Certificate of Birth Resulting in Stillbirth (PH-4107)
- Certificate of Adoption (PH-1248)
- Application for Report of Foreign Birth for Adopted Child (PH-2591)
- Affidavits of Natural Parents (PH-1859)
- Application for a Certified Copy of a Certificate of Death (PH-1663EN)
- Application for Verification of Death Facts (PH-3055)
- Application for a Certified Copy of a Certificate of Marriage (PH-1670EN)
- Application for Verification of Marriage Facts (PH-3331)
- Application for a Certified Copy of a Certificate of Divorce or Annulment (PH-1671EN)
- Application for Verification of Divorce or Annulment Facts (PH-3332)
- La Versión en Español
Governor Bill Haslam
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