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FORMS |
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Apply |
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General
Applications, Intent, Permits, Background
Check |
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Permit to Operate |
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Click
Here
for the NYS Application for Permit to Operate Form (general application for
all) |
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Change of Permit Holder |
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Click
Here
for the Change of Permit Holder Form (not for children's camps) |
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Notice Of Intent |
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Click Here
for the Notice of Intent Application (application for new projects,
changes) |
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NYS Registry Check |
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Click
Here for the NY State Central Registry Database Check Form (DSS3370) |
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Tobacco Vendor |
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Click Here for
the NY State Registration to Apply as a Tobacco Vendor Form
(DTF-716) |
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Corp. Form |
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Click Here
for the Corporation Form (if you are a corporation) |
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Job-Exam Application |
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Click Here for the Application for Exam or Employment with
Clinton County |
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Consent |
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Consent, Waiver,
Proxy |
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NYSIIS Consent |
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Click Here
for the NYSIIS Consent Form for Age 19 or Older |
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NYSIIS Withdrawal |
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Click Here
for the NYSIIS Withdrawal Form for Age 19 or Older |
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Records Release |
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Click Here
for the Records Release Form |
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Health Care Proxy |
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Click Here for the NYS Health Care Proxy Form (assign someone
for your health decisions) |
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Waive Workers Comp |
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Click Here for
the NYS Affidavit for No Worker's Compensation (WC/DB-100) |
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Complaint |
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All Complaints,
Report an Animal Bite |
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Nuisance Report |
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Click Here
for the Nuisance Complaint Report (animals, food, smoking, vermin, sewage, etc) |
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Animal Bite |
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Click Here
for the Reporting an Animal Bite Form (any animal bite) |
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Food |
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Food
Service Permits, Catering |
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FSE Permit |
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Click Here
for the Food Service Establishment Permit (restaurants, large groups,
etc) |
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Catering Off-Site |
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Click Here for
the Off-Site Catering Forms (permission for catering off-site) |
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HACCP - Blank |
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Click Here for the
Hazard Analysis Critical Control Point Blank Worksheet |
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HACCP - NYSDOH |
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Click Here for the
NY State Department of Health's Generic HACCP Plan (rev. 2006) |
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"Doggy Bag" Labels |
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Click Here to
print out the "doggy bag" labels (Avery
5163 2” x 4” mailing labels) |
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"Doggy Bag" Template |
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Click Here
to save the "doggy bag" labels template to modify (rich text format
- rtf) |
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IST |
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Individual Sewage
(septic) Treatment Packet |
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IST |
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Click Here for
Individual Sewage Treatment Packet (permit, applications) |
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Realty Subdivision |
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Subdivision
Documents |
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Subdivision |
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Click Here
for the Subdivision Checklist (engineers checklist for subdivisions) |
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WIC |
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Women, Infants,
Children Downloadable Forms |
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WIC |
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Click Here for WIC's
Downloadable Forms Page (applications, diet, income, changes, proxy) |
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Migrant |
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Migrant Housing
Unit Forms |
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Migrant Inspect |
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Click Here for
the Migrant Farm Housing Unit Pre-Operational Inspection Form |
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Water |
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Public Water,
Water Reports, Water Changes, Beaches, Pools Documents |
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PWS Changes |
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Click Here for the Public Water System Report a Change Form
(to report emergency changes) |
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Water Sys. Op Report |
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Click Here for
the NYS Chlorination Water System Operation Report (DOH360CFL) |
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Water Sys. UV Report |
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Click
Here for the Clinton County UV Water System Operation Report |
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Water Op's Calendar |
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Click Here
for the Clinton County Water Operator's Calendar for this Year |
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Water Disinfection App |
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Click Here
for the Clinton County Water System Disinfection Application Packet |
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Beach Safety Plan |
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Click Here for the Swimming Beach Safety Plan (MS Word document) |
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Beach Daily Op Report |
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Click Here for the Daily Report on Beach Operations Form
(DOH2287) |
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Beach Engineering Rpt |
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Click
Here for the Engineering Report for Bathing Beaches (DOH2436) |
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Pool Safety Plan |
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Click Here
for the Pool Safety Plan (MS Word document) |
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Pool Daily Op Report |
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Click Here
for the Daily Report on Pool Operations Form (DOH1323) |
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Pool Plan Checklist |
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Click
Here
for the Swimming Pool Checklist (DOH2434) |
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Pool Engineering Rpt |
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Click
Here for the Engineering Report for Swimming Pool Plans (DOH1309) |
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Public Gatherings |
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Public Gatherings
/ Functions Documents |
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Public Function Rpt |
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Click Here for
the Public Function Event Report Form (DOH2332-Emergency Medical
Services) |
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Public Function Permit |
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Click Here for the
Application for a Permit for a Public Function (DOH44) |
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Children's Camps |
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Children's Camp
Forms |
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Child Camp Staff |
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Click Here for
the NYS Children's Camp Facility & Staff Description Form (DOH367) |
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Child Camp Add Staff |
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Click Here for
the NYS Children's Camp Additional Staff Qualification Form
(DOH367a) |
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Child Camp Safety |
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Click Here for the NYS Children's Camp Safety Plan Addendum to
Subpart 7-2 |
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Child Camp Bed Rails |
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Click Here for the "Bunk-Bed Rail" Requirements (CPSC safety
standard for camps) |
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Other |
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Vaccination
Records, Safety, CPR Wall Chart, Sanitary Code |
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Vaccination Record |
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Click Here for the Adult Vaccination Record Form (to help keep
track of your vaccinations) |
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Fire Safety Training |
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Click Here for the CCHD Checklist for Employee Fire Safety
Training Plan |
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CPR Wall Chart |
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Click Here for the
NYS CPR (Blank) Wall Chart |
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Sanitary Code |
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Click Here
for the Clinton County Sanitary Code (2008) |
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INFORMATIONAL |
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Food |
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FSE Water
Emergency, Cooking Temperatures, Choking Posters |
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Food Water Emerg |
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Click Here for the Food Service Establishment Water Emergency
Document |
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Food Cooking Temps |
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Click Here
for the Food Temperature Guidelines Document (what temperatures to
cook food) |
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First Aid Poster (Eng) |
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Click Here
for the Choking First Aid Poster (English) |
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First Aid Poster (Spn) |
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Click
Here for the Choking First Aid Poster (Spanish) |
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Bake Sale Savy |
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Click Here for
information on tips for having a Bake Sale |
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Water |
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Drillers,
Disinfection, Fluoride, Safety, Labs |
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Water - Well Drillers |
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Click
Here for the List of Certified Well Drillers in NY State |
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Water - Testing Labs |
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Click
Here for the List of NY State Approved Water Testing Labs |
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Water - Disinfection |
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Click
Here for the Well Disinfection Instructions (how to disinfect
your private well) |
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Water - BWO |
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Click Here for
Boil Order Water Instructions (public instructions about how to boil water) |
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Water - with Fluoride |
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Click
Here for the List of Community Water Systems with Fluoride |
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Beach - Safety Equip |
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Click
Here for the "Required Safety Equipment" Chart (for
Beach Facilities) |
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Pool - Safety Equip |
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Click
Here for the "Required Safety Equipment" Chart (for
Pool Facilities) |
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Pool - Disinfection |
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Click
Here for the Pool Disinfection Requirements Chart (for Pool
Facilities) |
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Bats |
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Bat Encounter |
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Bats - at Child Camps |
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Click Here
for the "Bat Management" Poster (for camps to display) |
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Other |
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Camp Listing ,
New Business Startup Phone List |
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Child Camp List |
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Click Here for a List of Clinton County Overnight and Day
Children Camps (contact info) |
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New Bus. Info |
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Click
Here for the Getting Started List of Telephone Numbers (for
starting a new business) |
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CCHD Brochure |
|
Click Here
for the Clinton County Health Department's Brochure |
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