DOH Forms
Additional Health Department Forms

Forms for Public Health Services


Public Health, Sanitation and Safety Program
Form # Title PDF/WORD Instruction/ Comments
CB-2 Fatal/Serious Accident Report pdf 23k
doc 99k
 
CB-11 Application for Certificate of Approval
to Operate a Youth Camp
pdf 16k
doc 61k
 
CB-14 Application for Certificate of Approval>
to Operate a Youth Camp
[Single Sport Youth Camp (SSYC)]
pdf 18k
doc 87k
 
CB-15 Annual Accident Report Youth Camp Safety Act pdf 13k
doc 65k
Instructions and Codes for Annual Accident Report
pdf 10k
doc 24k  
CB-17 Youth Camp Self-Inspection Report (for Youth Camp Operators) pdf 23k
doc 125k
 
CB-18 Youth Camp Safety Detailed Data Sheet (for Local Health Inspectors) pdf 69k
doc 224k
 
CB-19 Youth Camp Safety Detailed Data Sheet (for Youth Camp Operators) pdf 74k
doc 319k
 
CB-20 Certification for the Replacement of Main Drain Covers in Pool/Spa pdf 20k
doc 55k
 
CEOH-1 Checklist for Public Recreational Bathing Facilities pdf 20k
doc 101k
 
EHS-11 Inspection of Bathing Beaches pdf 20k
doc 62k
 
EHS-12 Inspection of Hot Tubs/Spas pdf 24k
doc 66k
 
EHS-13 Inspection of Swimming Pools pdf 24k
doc 80k
 
EHS-14 Inspection of Swimming Pools, Hot Tubs and Spas pdf 29k
doc 119k
 
PHSS-1 Application for Tanning Facilities Registration pdf 22k
doc 80k
 
PHSS-2 Warning Statement and Tanning Authorization pdf 27k
doc 36k
 
PHSS-3 Tanning Facility Inspection Checklist pdf 31k
doc 56k
 
PHSS-4 Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects (FY 2013) pdf 8k
doc 8kk
 
PHSS-4 Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects (FY2014) pdf 8k
doc 29k
 
PHSS-5 Payment Voucher, Tanning Facility Inspections (FY 2013) pdf 37k
doc 59k
Instructions for Completing the PHSS-5 Payment Voucher
pdf 9k
doc 23k  
PHSS-5 Payment Voucher, Tanning Facility Inspections (FY 2014) pdf 31k
doc 58k
Instructions for Completing the PHSS-5 Payment Voucher
pdf 9k
doc 23k  
PHSS-6 Confidential Medical Waste Exposure Report pdf 22k
doc 57k
 

Body Art
For Local Health Officials Only
Form # Title PDF/WORD Instruction/ Comments
EHS-34 Application for Approval to Operate a Body Art Establishment (Permanent) For use by Local Health Department Officials only. pdf 17k
doc 72k
 
EHS-35 Application for Approval to Operate a Body Art Establishment (Temporary) For use by Local Health Department Officials only. pdf 16k
doc 60k
 
EHS-36 Body Art Infection/Injury Report For use by Local Health Department Officials only. pdf 33k
doc 91k
 
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