Health: Intranet: Forms

Administrative Services

Form Name	Instructions	Form
Driver's Checklist		PDF DOC
Incident Report - State Form 52359		Form
Request for Internal Access - State Form 52120		Form
ISP Bomb Threat - State Form 24353		Form
Print Request - State Form 44874		Form
Print/Copy Requests General Information and FAQ's		Word
Credential and Access form - State Form 52044		Form
Record Transmittal and Receipt - State Form 23628		Form
Release From Liability For Non-State Employee Passenger in State Vehicle - State Form 50188		Form
Request for Approval of New/Revised Form - State Form 36040	Instructions Forms Coordinator Handbook	Form
Request for Records State Form 24019		Form
Rental Vehicle Use Agreement - State Form 53553		PDF DOC
Temporary Vehicle Agreement - State Form 52297		Form
SF16 - Records Destruction Notification		Form
SF48883 - State Archives Record Transmittal and Receipt		Form

Commissioner's Office

Form Name	Instructions
Official Letterhead in Word	Brand Resources

Finance

Form Name	Instructions	Form
Assessment Criteria	Instructions
Authorization for Out of State Travel (formerly G-10) - State Form 823		Form
Certification for Missing Receipt - State Form 42275		Form
Cheat Sheet	Instructions	Form
Employee Statement of Employer Provided Vehicle Use - State Form 49632		Form
Indiana Business Preferences	Instructions
Indiana Economic Impact Form - State Form 51778		Form
Requisition/Purchase Order - State Form 37773		Form
Official Station		Form
Record of Telephone Price Quotations - State Form 43464		Form
Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement for Employees Using the IDOH Fitness Center State Form 54729		Form
Report of Collections/Receipts (Due Treasurer of State) - State Form 14311		Form
Request for Special Procurement - State Form 54650		Form
Surplus Spreadsheet	Instructions	Form
Temporary Employee Request	Instructions and Templates
Strategic Hiring Request Template for Knowledge Services Positions	Forms
Job Description for Knowledge Services Requests Template	Form
Travel Advance - State Form 49630	Instructions	Form
Travel Status Memo	Instructions	Form
Vendor Information Form State Form 53788		Form

Grants Resource Center

Form Name	Form
Request to Acquire New Funding - State Form 51757	Form
Grant Award Notification Template	Form

Human Resources

Form Name	Form
First Report of Injury/Illness - State Form 34401 (R10/1-02)	Form
Outside Employment Disclosure - State Form 53182	Form

Office of Legal Affairs

Form Name	Form
Agreement for Release of Data Containing Confidential Information State Form 52104	Form
Request For Approval of Memorandum of Understanding State Form 53555	Form
Consent To Release Social Security Number - State Form 53190	Form
Request for Internal Legal Advice
Request for Approval of Special Agreement - State Form 53676	Form
Request for Assistance with Contract, Memorandum of Understanding (MOU) or Special Agreement - State Form 53559	Form
Request for Assistance with Rules Promulgation - State Form 52702	Form
Data Sharing Agreement template - Internal Data Sharing Agreement template - External	Link Find under “Responsible Data Sharing.”

Office of Technology and Cybersecurity

Form Name	Form
Virtual Private Network (VPN) Request-Agreement State Form 55278	Form
Database Access Form - State Form 55859	Form
Justification for Purchase of Removable Media Devices State Form 55872	Form
Personal Device Connection to State E-mail System Agreement - State Form 55610	Form
Request for Internal HIPAA Advice - State Form 51245	Form
Receipt of Mobile Device State Form 55953	Form