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NC Department of Health and Human Services
NC Division of Public Health
N.C. Public Health Home
 
 

Forms

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 Administration

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Cellular Phone Services/Pager Request Authorization and Change Form PDF N/A Submitted by employee to supervisor for approval before determining if equipment can be reassigned or must be procured.
Cellular Telephone User Acknowledgement Form PDF N/A Each individual with a state-assigned cellular phone must sign.
DPH Access Badge/Card Request (Downtown) DOC N/A Badge request form for DPH employees located in downtown Raleigh facilities; NOT for Dix Campus (Royster).
Dix Campus Identification (ID) Badge/Swipe Card Request Form DOC, 75 KB 02/11/15 DHHS Dix Campus (e.g., Royster) ID Badge form; DIRM form.
DPH Six Forks Campus ID/Card Building Access Badge Request PDF, 18 KB 04/14/14 Badge request form for DPH employees on Six Forks Campus.
State Property Incident Report external link DOC N/A For use by state department head to report to the Director of the State Bureau of Investigation information or evidence of an attempted arson, damage to, theft from or theft of, or embezzlement from, or misuse of any State owned, personal property, buildings or other real property.

 Budget - Updated 06/04/18

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Budget Revision Worksheet XLS, 68 KB 12/10/10 Budget revision worksheet.
Cash Management Exception (CME) Form DOC, 36 KB 01/24/18

Form to use for requesting an exception to cash management plan policy for business expenses such as travel.

Cost Allocation Plan (CAP) Update Request DOCX, 56 KB 05/15/13 Form used by the Cost Accounting Branch in establishing and maintaining the Cost Accounting Plan; documents the initiation of cost centers (RCCs) as well as changes to existing centers.
Cost Allocation Plan (CAP) Update Request Instructions DOC, 57 KB 05/15/13 Instructions for completing the Cost Allocation Plan (CAP) Update Request.
Cost Allocation Timesheet XLS, 41 KB 06/16/14  
Cost Allocation Timesheet Instructions PDF, 97 KB 06/16/14  
Cost Allocation Timesheet Procedures for Admin Staff PDF, 42 KB 06/16/14  
Cost Allocation Timesheet Procedures for Business Officers PDF, 44 KB 06/16/14  
Direct Hotel Prepay Template DOCX, 500 KB 06/04/18  
Direct Pay Letters Template DOC, 511 KB 06/04/18  
DPH Business Operations Meeting Agenda Template DOC, 91 KB 09/23/10  
Fixed Asset Input Form and Instructions XLS, 115 KB 10/03/17 DHHS Form for inventorying fixed assets.
FAS-1 Change Form XLSX, 17 KB 01/25/18  
ICD-10 Project Timesheet XLS, 17 KB N/A
ICD-10 Project Timesheet Sample XLS, 17 KB N/A
Instructions for Non-Budget Personnel Completing Project Timesheet DOC, 19 KB N/A
ITS E-Billing Change in Department Code DOC, 27 KB 06/17/11 Form for Changing ITS E-Billing Department Codes.
ITS E-Billing for Adding/Deleting Users DOC, 30 KB 06/17/11 Form for Requesting New ITS E-Billing Users or Adding, Deleting, or Changing ITS E-Billing Users.
Reclassification Forms with Instructions XLS, 52 KB 06/14/11 Workbook that includes forms for journal voucher reclasses, contract payment reclasses and other reclasses.
Substitute W-9 N/A N/A State of NC Substitute W-9 Form

 Conference Authorization - Updated 06/04/18

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Conference Authorization Form XLS, 213 KB 06/04/18 A Conference Authorization Form must be utilized to document approval of any Conference by the Division Director/Designee, even when there are no costs associated with the Conference.
DPH Conference Services Policy PDF 08/14/17  
DPH Conference Services Contract DOC 08/14/17  

 Contracts

 Grants Management

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
606A Form: Notification of Application for Grant Funds/Awards N/A N/A State agencies are required by statute (G.S. 143C-7-1) to notify the Office of State Budget and Management (OSBM) of all applications made for grant funds and/or other funds that require an application.
606A Instructions: Instructions for Reporting Grant Applications/Awards N/A N/A Line-by-line instructions for Form 606A
Cost Allocation Plan (CAP) Update Request DOCX, 56 KB 05/15/13 Form used by the Cost Accounting Branch in establishing and maintaining the Cost Accounting Plan; documents the initiation of cost centers (RCCs) as well as changes to existing centers.
DPH Business Operations Meeting Agenda Template DOC, 91 KB 09/23/10  
N/A 12/30/15 DHHS worksheet forms for submitting grant proposals.
Request for Allocated Overhead Estimate for Grant Applications XLS, 31 KB 04/23/13 N/A
SF 424: Application for Federal Assistance PDF N/A From grants.gov website
SF 424A: Budget Information - Non-Construction Programs PDF N/A From grants.gov website
SF 424A Example and Instructions DOC, 390 KB 01/22/09 SF 424A example provided by DPH
Draft Prior Approval for Grant Action PDF, 98 KB 10/22/15 Current guidance on level of approval required for grant actions.

 Human Resources

 Motor Fleet - Updated 06/04/18

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Accident Reporting Form/Vehicle Accident Report PDF N/A Motor Fleet Management's vehicle accident reporting form.
DHHS FM-30 Application for Permanent Passenger Vehicle DOC N/A Application for permanent passenger vehicle.
DHHS FM-30 Form Instructions PDF N/A Instructions for DHHS FM-30
DOT Gasoline Facilities/Automated Fuel Sites HTML N/A Automated fuel sites in NC.
DPH Car Wash Log XLS, 25 KB 04/12/11 DPH car wash log form for Motor Fleet Vehicles.
Minimum Mileage Exception PDF N/A  
Motor Fleet Rates PDF N/A  
Reimbursement Request XLS N/A  
State Property Incident Report external link DOC N/A For use by state department head to report to the Director of the State Bureau of Investigation information or evidence of an attempted arson, arson, damage to, theft from, or theft of, or embezzlement from, or misuse of any State owned personal property, buildings or other real property.
Travel Log PDF, 256 KB N/A Motor Fleet Management Form FM-12e

 Purchasing - Updated 05/23/18

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Cellular Phone Services/Pager Request Authorization and Change Form PDF N/A Submitted by employee to supervisor for approval before determining if equipment can be reassigned or must be procured.
Cellular Telephone User Acknowledgement Form PDF N/A Each individual with a state-assigned cellular phone must sign.
Correction Enterprises Print Order Form (DC 258) DOC N/A Complete for publication print orders.
Fixed Asset Input Form (FAS-1) and Instructions XLS, 115 KB 10/03/17 DHHS Form for inventorying fixed assets.
DHHS Publication Review (PA-2) PDF N/A DHHS approval form for print and web materials. Call 707-5053 to talk with your Public Information Officer.
DHHS Publication Review (PA2) Translated Materials PDF N/A DHHS approval form for print and web materials that require translation.
DPH Purchase Request Form XLSX, 38 KB 10/18/17 DPH Purchase Request form used for ordering supplies, materials, and other equipment. When downloading, a box may appear with an “ok” button near bottom of box; click the button to utilize form.
DPH Purchase Request Form Instructions PDF, 24 KB 10/18/17 Instructions for using the DPH Purchase Request Form (see above).
Justification for Information Technology E-Procurement Request (DIRM) DOC, 53 KB N/A Justification and contact information for e-procurement request.
Maintenance Service Contracts Questionnaire DOC, 25 KB 03/17/14 Questions that must be answered to support and get approval for maintenance contracts.
State Property Incident Report external link DOC N/A For use by state department head to report to the Director of the State Bureau of Investigation information or evidence of an attempted arson, damage to, theft from or theft of, or embezzlement from, or misuse of any State owned, personal property, buildings or other real property.
Substitute W-9 N/A N/A State of NC Substitute W-9 Form
Telecommunications Cable Service Request (TO-4) DOC N/A Request cable services from ITS.
Telephone Order Service Request (TO-5) DOC N/A Request telephone services from ITS.
Telephone Order Service Request (TO-5) Instructions DOC N/A Instructions for Form TO-5 to request telephone services from ITS

 Records Management

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Public Records Series Listing 99-S PDF N/A Complete if a schedule needs to be developed and if a schedule needs to be updated.
Records Retrieval Form PDF N/A Use to request records stored at the State Records Center or other storage facilities.

 Risk Management

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Conflict of Interest N/A N/A N/A
Federal False Claims Act Education Employee Notice DOC, 33 KB 06/07/16 N/A

 Travel

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Cash Management Exception (CME) Form DOC, 36 KB 01/24/18

Form to use for requesting an exception to cash management plan policy for business expenses such as travel.

DHHS Travel Authorization Form XLS N/A DHHS travel authorization form
DHHS Travel Reimbursement Form XLS N/A DHHS travel reimbursement form
DHHS Travel Expense Reimbursement Form for Board/Committee Members XLS, 757 KB N/A DHHS travel reimbursement form for board members
NC Quick Pass Business Account Application Form PDF N/A NC Quick Pass is a pre-paid account used for all electronic toll collection.
Payment Verification Form DOCX, 78 KB 03/19/18 Direct deposit of travel reimbursement (NOT monthly payroll).