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 (Updated Jan 17) pdf 52k
doc 129k
 
CB-11 Application for Certificate of Approval to Operate a Youth Camp pdf 324k
 
Click here to pay online  
CB-14 Application for Certificate of Approval to Operate a Youth Camp
[Single Sport Youth Camp (SSYC)]
pdf 419k
 
Click here to pay online  
CB-15 Annual Accident Report Youth Camp Safety Act pdf 1601k
 
 
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 (Updated Jan 17) pdf 160k
doc 104k
 
PHSS-1 Application for Tanning Facilities Registration
(Updated August, 2016)
pdf 20k
doc 78k
 
PHSS-3 Tanning Facility Inspection Checklist
(Updated August, 2016)
pdf 26k
doc 56k
 
PHSS-4 Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects (FY 2017) pdf 8k
doc 29k
 
PHSS-4 Signature Page, Acknowledging Receipt of Grant Agreement for Special Health Projects (FY2018) pdf 15k
doc 18k
 
PHSS-5 Payment Voucher, Tanning Facility Inspections (FY 2017) pdf 31k
doc 60k
Instructions for Completing the PHSS-5 Payment Voucher
pdf 9k
doc 23k  
PHSS-5 Payment Voucher, Tanning Facility Inspections (FY 2018) pdf 38k
doc 26k
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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