Instructions
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Water Well Construction Report Instructions - PDF
<> Facility Information Change Form - Fillable PDF*
Instructions
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If you already have an account, log in. <>/Border[0 0 0]/H/N/Rect[48.5 279.61099 203.00702 269.61099]/Subtype/Link/Type/Annot/URI(http://dph.illinois.gov/topics-services/emergency-preparedness-response/ems/res_sysListing)>> <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[0.0 0.0 792.0 612.0]/Type/Page>> 0000002154 00000 n
Cancellation of Employment/Supervision of Apprentice-
Plumbing Contractor Surety Bond Forms
Dental Examination Waiver Form - PDFEn Espaol - PDF, Discharge and Opportunity for Hearing for Nursing Home Residents, Notice of Involuntary Transfer or, Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form - En Espaol - Fillable PDF*, Alternate Rural Staffing and Response Authorization Request - Fillable PDF
Lead Third Party Examination
%%EOF
Water Well Pumps, Installation Report for - Fillable PDF*
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Reciprocity with the City of Chicago, Application for -
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Lead Contractor Application
Trauma Nurse Specialist Course Coordinators (TNSCC) Testing Application Submission
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EMS - Service Information. Residency Involuntary Termination Form - PDF
*These are draft forms pending final approval of the rules. Irrigation Employee, Notice of Cancellation of Employment Registered - PDF
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Electronic Roster for Plumbers Continuing Education
Facility Information Change Form - Fillable PDF*, Application for Registration of Continuing Education - PDF
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Plumber's
Assessor, Application - PDF - Instructions
Agency Licensing Renewal/Change of Ownership Application - Fillable PDF*
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2023.2.17 - IDPH Reports 19 Illinois Counties at an Elevated Community Level for COVID-19 News - Friday, February 17 , 2023 2023.2.10 - IDPH Reports 15 Illinois Counties at an Elevated Community Level for COVID-19 Agency Add or Removes Services, Hospice Residence Initial/Renewal Application, Irrigation Contractor, Application for Registration for, Contractor's Test Certificate Lawn Sprinkler System, Irrigation Contractor Application Child Support Certification, Plumbing Contractor Registration Online Renewals, Irrigation Employee, Notice of Cancellation of Employment Registered, Irrigation Employee, Application for Registration for, Lawn Sprinkler System, Contractor's Test Certificate, Communicable Diseases Laboratory Test Requisition, Request for Respiratory/Influenza Testing, Lead Abatement/Mitigation Project, Notice of Commencement, Lead Assessment Form, Public Health Nurse Home, Lead Program Contact Record and Order Form, Lead Contractor Application
Assessor, Application, Lead Third Party Examination
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Illinois Emergency Medical Systems (EMS) license enclosed License #_____ I have attached my written request to the EMS medical director for inactive status. Rabies Submission Form - PDF
- Partnership - PDF
IDPH Board. Plumbing Contractor Registration Online Renewals
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endobj Note any name or address changes or corrections in the appropriate space. Facility Information Change Form - Fillable PDF*
There is also a collection of 2.3 million modern eBooks that may be borrowed by anyone with a free archive.org account. HWkO_Q|X4mvugL!am' ANU:e qC 72i;> `: _Bs|L{_h['j STEP 2: Contact the LEMSS office To notify the System of your address change. Division of EMS and Highway Safety's on-line licensing site. and patient care in emergent and non-emergent settings. a>a8p
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Dialysis Medicare Certification, End Stage Renal Dialysis Medicare Certification, Freestanding Emergency Center (FEC) Initial Licensure Application, Freestanding Emergency Center (FEC) Renewal Licensure Application, Project Submission Form for Freestanding Emergency Center, Health
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public education, fire inspections, etc.) Health Agency Agency Supervisor Qualifications Review - Attachment B, Home Health Agency
Application for Exemption from Certificate of Need Review and Permit
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Legal Guardian Registration Forms, Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Application/Eligibility Voucher for Low-Cost Spay/Neuter - Fillable PDF*, Veterinarian Application/Agreement to Participate - Fillable PDF*, Asbestos Abatement Notification Form - Fillable PDF*, Asbestos Contractor Application
Agency Branch Questionnaire - Fillable PDF*
Application (General Use), Structural Pest Control Technician
0000038473 00000 n
Springfield: 217-52 4-DoIT (217-524-3648) Chicago: 312-81 4-DoIT (312-814-3648) Technical Support Week Days (8A-5P, Monday-Friday) Contact the IDPH Helpdesk at 866-220-5247 or via email at DPH.Helpdesk@illinois.gov for Portal access and web-based application support. 0000001085 00000 n
Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF*
Phone Number: ( ) _____ Address change Level of license: EMT-B EMT . To change your address with the Department of Public Health, click on the link for Online Services. To pay your license fee with the Department of Public Health, which you must do before you can receive a license, click the link for Online Services. If so, what system number? Stretcher Van Inspection Form - Fillable PDF
4. 40 0 obj Out of State CNA Application - PDF
FSSMC Request for Reciprocity - PDF, Request for Certificate of Free Sale - form and preparation guidelines - Fillable PDF*
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A person currently licensed as an EMT, Intermediate, or Paramedic may only use their EMS license in 'u s1 ^
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- Limited Liability Company - PDF
Lead Training Course Roster - PDF
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PDF, Affidavit of No Employees - PDF
Birth Parent Registration Forms
0000044461 00000 n
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Under the general direction of the Lieutenant, the Firefighter/EMT - Firefighter/Paramedic performs fire suppression, rescue operations, fire prevention activities (e.g. [28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R] Behavioral Risk Factor Surveillance System, Pregnancy Risk Assessment Monitoring System, Head/Spinal Cord and Violent Injury Registry (HSVI), EMS Dispatch Agency Certification Application, EMS Dispatch Agency Recertification Application, EMS Alternate Rural Staffing Authorization Request, EMS Ambulance Staffing Waiver Application, EMS Non-Transport Inspection Form Provider, EMS Non-Transport Application for Existing Transport Provider, Grant Accountability and Transparency (GATA). Birth Record Files of a Deceased Infant, Application for Search of - Fillable PDF*
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Matrix 4D - Project Cost and Fee Verification - Fillable PDF*
Which name do I submit for licensure? Multiple Hospice Location Questionnaire - PDF
Gestational Surrogate Form - PDF
Contractor's Test Certificate Lawn Sprinkler System - PDF
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Application for Restoration of Expired - PDF
trailer
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Requiring people to go through an administrative agency before filing a lawsuit is highly unusual. 0000043516 00000 n
How do I renew my EMT license if I am affiliated with an Illinois EMS system? (!qcP!>o1Z]P ,l7>Ge'?!QyAGa2BV!_
4fe@s|UY` EMS - Certification and Renewal Change of Iowa EMS Certification Level Application March 2021 Change of Iowa EMS Certification Status Application March 2021 EMS Application Affirmation Question Guidance Aug 202 2 EMS Continuing Education Audit Report Form Sept 2020 Extension of Iowa EMS Certification Application Sept 2020 The video recordings would be kept for at. Home Health
Involuntary Termination of Residency Forms
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UCIA Background Check Form
Hearing
Instrument Dispenser Inactive Status Request Form - PDF
<> Application for Retired, Plumber's License
2023 Iowa Department of Health and Human Services, Civil Commitment Unit for Sexual Offenders, Emergency Medical Services for Children (EMSC), Mobile Integrated Health - Community Paramedicine, Healthcare Coalitions Systems Development, Click HereFor Latest Information RegardingNovel Coronavirus (COVID-19), FAQ for IAC 131, 132, 139 and The Iowa EMS Provider Scope-of-Practice Sept 2019. <>/Border[0 0 0]/H/N/Rect[48.5 267.61099 200.46503 257.61099]/Subtype/Link/Type/Annot/URI(http://dph.illinois.gov/topics-services/emergency-preparedness-response/ems/res_sysListing)>> Facility Information Change Form - Fillable PDF*
Printed by Authority of the State of Illinois P.O.#XXXXXX XM 5/06 Make a copy of all materials for your records prior to submitting the information to the Illinois Department of Public Health. Report of Blood Lead Test Result - Filliable PDF, Certifications for Request for Inspection - Fillable PDF, Temporary Occupancy Policy - Fillable PDF*, Application for Manufactured Home Community (a/k/a Mobile Home Parks)
1st payout on 1st payroll check. 0000007026 00000 n
Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with .
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Eye Examination Waiver Form 2009 - PDF
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There is a $1.10 charge to change your address online. You may complete your renewal online at the website listed on the form. Please contact the Division at 217-785-2080 or at DPH.EMTLIC@illinois.gov with questions or for more information. ], Home Health, Home Services, Home Nursing and Placement
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Matrix 4B - Through Wall/Floor Penetrations - Fillable PDF*
Biological Father Affidavit
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Request for Manufactured Home Installation Seals and Certificates
An agency that desires to provide out-of-hospital emergency medical care shall apply to the Iowa Department of Public Health. Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Foreign Nurse Application - PDF
Cancellation of Employment/Supervision of Apprentice, Plumbing Contractor Application for Registration or Renewal, Allied Health Care Professional
Adult Surrendered Person
Independent EMS License Renewal Request Form - PDF
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HW]\G+1D +@bOW9iY.G_ry;{K?xO/MZ? Structural Pest Control: Business License
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name change information: *Must include stamped or certified document (or photocopy of a stamped or certified) of one of the following: marriage certificate divorce decree court order naturalization document Water Well Sealing Form - Fillable PDF*
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Designation/Re-Designation/Attestation of ASRH without National Certification - PDF, Attorney's Certification Form - PDF
Report - PDF
Medicare Certification - PDF
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Address Change Form Click here to Access Online Services or to Apply Online Iowa HHS Bureau of Professional Licensure 321 E. 12th St. Des Moines, IA 50319 Phone: (515) 281-0254 Fax: (515) 281-3121 Online Licensure Services: http://ibplicense.iowa.gov Email: PLPublic@idph.iowa.gov Office Hours: 0000019702 00000 n
Emergency Medical Services (EMS) Systems Licensing, Please contact the Division at 217-785-2080 or at. Hearing
5. Address changes can be made ON LINE in the IDPH database listed below. Surviving Relative of Deceased Adopted/Surrendered Person
Structural Pest Control Certificate of
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Nursing Student Application - PDF
License, permit, certification or registration will be mailed when eligibility has been established. rxxC6~qz=0vvvMz8 Q23%C#"vF_6(bP8$%v #~xyj 0000001009 00000 n
You will need a credit or debit card and a valid email address. Renewal Notice - PDF
Hearing Conservation Annual
The System files the appropriate paperwork with IDPH. Medical Student Scholarship
Manufactured Home Community Transfer Application
It costs nothing to change your name unless you want a duplicate license mailed out. Facility Information Change Form - Fillable PDF*
Application Licensure - Fillable PDF*
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IDPH Chicago Headquarters Offices 122 S. Michigan Avenue, 7th and 20th Floors Chicago, IL 60603 312-814-2793 69 W. Washington Street, 35th Floor Chicago, IL 60602 312-814-5278 IDPH Community Event Request Form Learn More Event/Outreach Request FOIA Requests News Media Language Access Services Hotline Numbers AIDS/HIV/STD 800-243-2437 Scholarship Program Application - PDF, School Physical -- Certificate of Child Health Examination Form, Integrated Pest Management Forms (See Integrated Pest Management)
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Hospice
Construction Award Form - PDF
IDPH EMS Licensing - For more information and to access the IDPH EMS licensing forms. 0000001193 00000 n
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5. Name changes must be processed with the IDPH EMS Division per the mail, submitting copies of legal documents acceptable to IDPH that verifies the name change. Plumber Application Child Support Certification - PDF
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Please allow 2-4 business days for your license to post in our systems and your license status to update. ;EXr
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Adoptive Parent Registration Forms
Plumber's
Lead Supervisor, Inspector, Risk
startxref
EMS Service Programs shall submit a completed application and documentation that they meet or exceed the minimum requirements of Iowa administrative code 641-132. Facility Information Change Form - Fillable PDF*, Rural Health Medicare Certification - PDF
Application for Restoration of Expired, Plumber's License,
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Licensees may utilize this site if all criteria are met as outlined in the letter accompanying your license renewal notice. %PDF-1.3
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Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Pregnancy Termination Initial Licensure - Fillable PDF*
Accredited, Asbestos Training Course Instructor Application, Asbestos Training Course Provider
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Facility
Gestational Surrogate's Husband - PDF
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License, Application for Examination for, Plumber's License,
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The Alabama Department of Public Health will verify an applicant's immigration status or naturalized/derived citizenship status using the SAVE Program effective August 1, 2016. Re-examination application, Designation/Re-Designation of CSC, PSC or ASRH with National Certification, Designation/Re-Designation/Attestation of ASRH without National Certification, Swimming Facility Construction Permit, Application for, Swimming Facility License, Application for, Swimming Facility Prequalification Application for Architects and Professional Engineers, Swimming Facility Prequalification Application for Contractors, Swimming and Beach Facility Online Renewal, Trauma Nurse Specialist (TNS) Application Instruction Guide, Trauma Nurse Specialist Course Coordinators (TNSCC) Testing Application Submission, Trauma Nurse Specialist (TNS) Examination Roster, Birth Record Files, Application for Search of, Birth Record Files of a Deceased Individual, Application for Search of, Birth Record Files of a Deceased Infant, Application for Search of, Correction of a Birth Certificate, Application for, Correction of a Death Certificate, Application for, Death Record Files, Application for Search of, Dissolution of Marriage/Civil Union Record Files, Application for Verification of, Marriage/Civil Union Record Files, Application for Verification of, Water Well, Application for Permit to Construct, Modify or Abandon a, Water Well Construction Report Instructions, Water Well Pumps, Installation Report for, Application for Licensed Water Well Contractor's Closed Loop Well Certification, Application for Permit to Construct, Modify or Seal a Closed Loop Well System, Application for Registration as a State Closed Loop Well Contractor, Examination Application for State Closed Loop Certification, Application for Original Youth Camp License, Application for Youth Camp Construction Permit. I understand that during my . 0000002756 00000 n
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Reciprocity with the City of Chicago, Application for, Plumbing Inspectors, Application for Examination for Certification of, Plumbing Notice of
Last 4 digits of SSN
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Plumber's License
Pregnancy Termination Renewal Licensure - Fillable PDF*
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Agency Medicare Certification - PDF
endobj Allow 2-3 weeks for processing. Physician's Statement Form - PDF, Trauma Nurse Specialist (TNS) Examination Application - Fillable PDF
Irrigation Employee, Application for Registration for - PDF
PROVIDING LIFE SAVINGS SOLUTIONS SINCE 2009. Section 515.300 Approval of New EMS Systems; Section 515.310 Approval and Renewal of EMS Systems; Section 515.315 Bypass or Resource Limitation Status Review; Section 515.320 Scope of EMS Service; Section 515.330 EMS System Program Plan; Section 515.340 EMS Medical Director's Course; Section 515.350 Data Collection and . 36 0 obj Lead Worker Application or En Espaol - PDF - Instructions
Application (Restricted Use), Structural Pest Control Technician
Hospice Administrative Staff Changes - PDF
from Vox: Next, housing reform must consider the many government administrative agency roles in supporting affordable housing. Request for Respiratory/Influenza Testing - PDF
ILLINOIS DEPARTMENT OF PUBLIC HEALTH Emergency Medical Systems and Highway Services . JB Pritzker, Governor Copyright 2023 Financial & Professional Regulation Form, Lead Risk Evaluation and Blood Lead Testing Guidelines, Lead Risk Assessment Questionnaire, Medical Childhood, Lead Supervisor, Inspector, Risk
Application, Apprentice, Plumber's
- Corporation - PDF
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endobj <> Much of the Illinois EMS licensing process can be accomplished online, using the links and forms available on this page. How to Search for Discipline and Public Actions Select the specific licensing board from the list to the left License, Application for Examination for - PDF
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Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF*
Insurance - PDF
Insurance, Structural Pest Control Technician
Military Personnel Application - PDF
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Address Change. Trauma Nurse Specialist (TNS) Examination Roster - PDF (Word), Eye Examination Report 2009 - PDF
Public Schools Form - Fillable PDF*, Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, Notice of, Affidavit of No Employees - PDF
- Limited Liability Company - PDF
Lawn Sprinkler System, Contractor's Test Certificate - PDF, Communicable Diseases Laboratory Test Requisition - PDF
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