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~ Most Requested Forms ~

 Application for Access to Dept. of Health Records - FOIL (.pdf)

 Community Event Request Form (.pdf)

 Tobacco Sale Registration and Permit Application (.pdf)

 Wastewater Disposal System Registration and Notice of Intent (SAN-36) (.pdf)
    - For homeowners and installers

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Food Service

 Food Establishment Self Inspection Checklist (HD-SAN141) (.pdf)
    - For use by food service operators and managers to facilitate compliance with the New York State Sanitary Code, Subpart 14-1.

 Temporary Food Service Permit Application (.pdf)

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General Engineering

 Application for Approval of Plans for Public Water Supply Improvements (DOH-348) (.pdf)
    - For use by engineers/licensed architects, operators

 Application for the Approval of Plans and Specifications for Construction of or Alteration to an Artificial Swimming Pool and Appurtenances (Gen-134) (.pdf)
    - For use by engineers/licensed architects, operators 

 Certification of Construction Compliance (HD-159) (.pdf)
    - For use by engineers/licensed architects, operators

 Engineering Report for Swimming Pool Plans (DOH-1309) (.pdf)
    - For use by engineers/licensed architects, operators

 Engineer's Certification of Public Water Improvement Project Completion (DOH-5025) (.pdf)
    - For use by engineers/licensed architects, operators

 Sewer/Water Adequacy for New/Revised Use (HD-ENH300) (.pdf)
    - For use by business owners and operators

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Health Care Providers

 Lyme Disease Investigation Form (.pdf)
    - For use by Health Care Providers.  For additional reporting requirements and forms, please visit our Healthcare Provider's Disease Reporting and Management page.

 Confidential Case Report (DOH-389) (.pdf)
    - For use by Health Care Providers.  For additional reporting requirements and forms, please visit our Healthcare Provider's Disease Reporting and Management page.

 DBCH Sexually Transmitted Disease Reporting Form (.pdf)
    - For use by Health Care Providers. For additional reporting requirements and forms, please visit our Healthcare Provider's Disease Reporting and Management page.

 Dutchess County Department of Behavioral & Community Health Suspected Rabid Animal or Rabies Exposure Report (.pdf)
    - For use by Health Care Providers to report a contact between a human and a potentially rabid animal.  The completed form should be faxed to the Dutchess County Department of Health at (845) 486-3545.

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Subdivision and Individual Lots

 Deep Test Results (HD-185) (.pdf)
    - For plan approval documentation by engineers/licensed architects

 Extension of Approval, Application for (HD-164) (.pdf)
    - For use by owners to request extension of expired or expiring approvals.

 Fill Section Certification (HD-5) (.pdf)
    - For plan approval documentation by engineers/licensed architects

 Low Yield Wells Approval Application (WW-2) (.pdf)
    - For use by homeowners

 Percolation Test Results (HD-184) (.pdf)
    - For plan approval documentation by engineers/licensed architects

 Plans for a Wastewater Disposal System, Application for Approval of (HD-1) (.pdf)
    - For plan approval documentation by engineers/licensed architects

 Residential Sewage Disposal System, Application for Approval of (SAN-34) (.pdf)
    - For use by building inspectors

 Waiver Request Form (HD-160) (.pdf)
    - For use for waivers from established codes and standards

 Wastewater Disposal System Registration and Notice of Intent (SAN-36) (.pdf)
    - For homeowners and installers

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Tobacco

 Tobacco Sale Registration and Permit Application (.pdf)

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Water Supply

 Application for Public Water Supply Permit (.pdf)
    - For use by owners

 Annual Water Quality Report Certification Form (.pdf)
    - For use by water operators

 Annual Water Quality Report Templates
    - For use by water operators

 Approval of <5 GPM Well, Application for (WW-2) (.pdf)
    - For use by owners

 Certificate of Waiver from Asbestos Sampling Requirement, Application for a (DOH-351) (.pdf)
    - For use by owners/operators

 Certificate of Waiver from Disinfection Requirement, Application for (DCHD-350) (.pdf)
    - For use by owners/operators

 Consecutive Agreement Information (DOH-CAI) (.pdf)
    - For use by owners/operators

 Designation of Water Operator in Responsible Charge (DOH-4204) (.pdf)
    - For owners/operators

 Sample Site Identification and Certification (.pdf)
    - For use by owners/operators 

 Water Well, Application to Construct or Abandon (SAN-35) (.pdf)
    - For use by well drillers

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Weights and Measures

 Precious Metal License Renewal (.pdf)

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Miscellaneous

 Application for Access to Dept. of Health Records - FOIL (.pdf)

 Community Event Request Form (.pdf)

 Data Request Form (.pdf) - Electronic Submission
    - Use the above version to complete the form online and submit it electronically.   You must have Adobe Acrobat Standard or Adobe Acrobat Professional installed on your computer to use this version of the form.

 Data Request Form (.pdf)
    - Use the above version to complete the form online then print it and fax it to the Dutchess County Department of Health at (845) 486-3561. This version can be completed using Adobe Reader only.

 Department of Health Website Satisfaction Survey

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A. K. Vaidian, MD, MPH,Commissioner of Behavioral & Community Health A. K. Vaidian, MD, MPH
Commissioner of Behavioral & Community Health
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