New Jersey Department of Military and Veterans Affairs
Division of Veterans Healthcare Services
FORMS APPENDIX

Short-Term Stay Application for Admission……………………………………..….02-02-001A

Short-Term Stay Check-Off List………………………………………………….….02-02-001B

Short-Term Stay Admission Agreement……………………………………………...02-02-001C

Resident Grievance and Referral Form…………………………………………….…04-02-009A

Preliminary Unusual Incident-Sentinel Event Report Form………………………….04-02-013A

DHSS Reportable Event Record/Report-AAS-45……………………………………04-02-013B

Admission Agreement………………………………………………………………...05-02-007A

Safe Smoking Assessment Form………………………………………………..…….09-02-005A

Appendix 1: Identity Theft Red Flags Mitigation
   and Resolution Procedures………………………………………………………… 13-02-010A

Appendix 2: New Jersey Dept. of Treasury Circular Letter –
   Statewide Non-Tax Debt Collection and Write-Off…………..……………………13-02-010B

Violence Prevention Committee –
    DMAVA Departmental Directive 230.80………………………………………….13-02-011A

Recording and Reporting of Occupational Injuries and
 Illnesses – NJOSH 300………………………………………………………………13-02-011B

Safe Patient Handling Committee – Resident Assessment Form…………………….13-02-012A

Safe Patient Handling Committee – Bariatric Toolkit………………………………..13-02-012B
           
Appointment and Consultation Tracking Form……………………………………….27-02-004A

Request for Furlough/Trip Medications Form…………………….29-02-004A

Destruction Log for Controlled Drugs……………………………… 29-02-004B

Section 41 - Physical Plant Vehicle Safety (PPVS) Forms:

Vehicle Request Form………………………………………………………………..PPVS-41-1

State Vehicle User Inspection Form………………………………………………….PPVS-41-2

Weekly Vehicle Check and Services Log……………………………………………PPVS-41-3

Initial Notice of Claim for Damages Against the State of New Jersey (short form)
Business Office – Lost or Damaged Property………………………………………..44-02-004A

Initial Notice of Claim for Damages Against the State of New Jersey (long form)
Business Office – Lost or Damaged Property………………………………………...44-02-004B

Business Office – OMB Circular Letter 07-02-OMB
    Insured Losses State Property…………………………………………………….44-02-004C

Business Office – Payment Voucher (Vendor Invoice) PV 6/93……………………44-02-004D

VA Form 21-527EZ – Fully Developed Claim (Pension)……………………………44-02-005A

VA Form 21-0779 – Request for Nursing Home Information
     in Connection with Claim for Aid and Attendance………………………………44-02-005B

Petty Cash Receipt Form……………………………………………………………..44-02-007A

Petty Cash Fund Reimbursement Form (AR 54-3)…………………………………..44-02-007B

Petty Cash Fund –
Department of Treasury Circular Letter 05-03-OMB………………………………..44-02-007C

Welfare Manual………………………………………………………………………44-02-008A

Processing Excess or Surplus State Property, Scrap and Waste
Department of Treasury Circular Letter 08-03-DPP………………………………....44-02-012A

Delinquent Accounts - Department of Treasury Circular Letter 06-03-OMB………44-02-013A

Delinquent Accounts – Department of Treasury Form AR900 and AR900A………44-02-013B

Delinquent Accounts Communication Log………………………………………….44-02-013C

Fixed Asset Inventory System- Department of Treasury Circular Letter 11-19-OMB –
   Asset Inventory Requirements………………………………………………….…44-02-016A

Fixed Asset Inventory System- Department of Treasury Circular Letter 01-07-OMB –
   Fixed Assets………………………………………………………………………44-02-016B

Revised:   June 2011