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Forms

Where available, you can submit a form by entering information in the appropriate text fields and clicking the Submit button.  Or, you can download forms and fill them out when it is convenient for you. Many of the forms still require your signature; please either mail or deliver these to our offices.

Please note, most Dutchess County forms are available as PDF documents. This format requires that you have Adobe Acrobat Reader installed on your PC. Click on the Adobe Acrobat Reader icon Adobe Acrobat icon to download a free copy of this software.

View All Dutchess County Forms (A - Z)

All DBCH Forms

Access to DBCH Records - FOIL Application (.pdf)

Use the Application for Access to Dept. of Health Records - FOIL Form (.pdf) to request Freedom of Information Law (FOIL) access to DBCH records.



Annual Water Quality Report Certification Form (.pdf)

The Annual Water Quality Report Certification Form (.pdf) is used by water operators.



Approval of Plans and Specifications for Construction of or Alteration to an Artificial Swimming Pool and Appurtenances (Gen-134) Application (.pdf)

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



Approval of Plans for Public Water Supply Improvements (DOH-348) Application (.pdf)

The Application for Approval of Plans for Public Water Supply Improvements (DOH-348) Form (.pdf) is used by engineers/licensed architects, operators.



Certificate of Waiver from Asbestos Sampling Requirement, Application for a (DOH-351) (.pdf)

Complete the Certificate of Waiver from Asbestos Sampling Requirement, Application for a (DOH-351) Form (.pdf) and return to DBCH.



Certificate of Waiver from Disinfection Requirement, Application for (DCHD-350) (.pdf)

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



Certification of Construction Compliance (HD-159) (.pdf)

  The Certification of Construction Compliance (HD-159) Form (.pdf) is for use by engineers/licensed architects, operators.



Children’s Camp Epinephrine Administration Report Form (.pdf)

Children’s camps must report epinephrine administration to the local health department whether or not they are participating in the auto injector program and regardless if medication was from the camp’s stocked supply or brought to camp by a camper or staff.  Epinephrine Administration Report Form (.pdf)



Children's Camp Allegation of Abuse Report Form (.pdf)

This form is to be used by owner/operator to Report Allegation of Abuse (.pdf) at a children's camp facility.



Children's Camp Illness and Outbreak Report Form (.pdf)

This form is to be used by owner/operator of children's camp to report an Illness and Outbreak at a children's camp facility.



Children's Camp Injury Report Form (.pdf)

The Injury Report Form (.pdf) is to be used by owner/operator to report an injury at a children's camp.



Community Event Request Form (.pdf)

Complete the Community Event Request Form (.pdf) and return to DBCH.



Confidential Case Report (DOH-389) (.pdf)

Complete the Confidential Case Report (DOH-389) Form (.pdf) and return to DBCH.



Consecutive Agreement Information (DOH-CAI) (.pdf)

The Consecutive Agreement Information (DOH-CAI) Form (.pdf) is for use by owners/operators.



Contracted Services and Programs

The Contracted Services Policies and Procedures Manual (.pdf) as well as common forms used by departments in the County for human service contracts can be found at DutchessNY.gov/Contracted Services



Data Request Form (.pdf) - Electronic Submission

Use the Data Request Form (.pdf) - Electronic Submission (.pdf) to complete the form online and submit it electronically. 



DBCH Sexually Transmitted Disease Reporting Form (.pdf)

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



Deep Test Results (HD-185) (.pdf)

  The Deep Test Results (HD-185) Form (.pdf) is for plan approval documentation by engineers/licensed architects.



Dutchess County Department of Behavioral & Community Health Suspected Rabid Animal or Rabies Exposure Report (.pdf)

The DBCH Suspected Rabid Animal or Rabies Exposure Report Form (.pdf) is 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 Behavioral & Community Health at 845-486-3545.



Engineering Report for Swimming Pool Plans (DOH-1309) (.pdf)

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



Engineer's Certification of Public Water Improvement Project Completion (DOH-5025) (.pdf)

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



Extension of Approval, Application for (HD-164) (.pdf)

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



Fill Section Certification (HD-5) (.pdf)

The Fill Section Certification (HD-5) Form (.pdf) is for plan approval documentation by engineers/licensed architects



Food Establishment Self Inspection Checklist (HD-SAN141) (.pdf)

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



Low Yield Wells Approval Application (WW-2) (.pdf)

The Low Yield Wells Approval Application (WW-2) Form (.pdf) is for use by homeowners.



Lyme Disease Investigation Form (.pdf)

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



Percolation Test Results (HD-184) (.pdf)

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



Permit to Sell or Distribute Tobacco Products

Complete the Permit to Sell or Distribute Tobacco Products Form (.pdf) in Dutchess County and return to DBCH.



Plans for a Wastewater Disposal System, Application for Approval of (HD-1) (.pdf)

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



Precious Metal License Renewal, change for Information and Service of Process Forms (.pdf)

Complete the forms and return to:
DBCH
Division of Weights and Measures
98 Peach Road
Poughkeepsie, NY 12601

Questions?  Call 845-486-2949



Project Review and Permit Status

Use the Project Review and Permit Status tool to search for property parcels within Dutchess County and review the status of any project submitted to Environmental Health Services (EHS) division of the Dutchess County Department of Behavioral & Community Health (DBCH).



Public Water Supply Permit Application (.pdf)

The Application for Public Water Supply Permit (.pdf) is for use by owners.



Residential Sewage Disposal System, Application for Approval of (SAN-34) (.pdf)

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



Sample Site Identification and Certification (.pdf)

The Sample Site Identification and Certification Form (.pdf) is for use by owners/operators.



Sewer/Water Adequacy for New/Revised Use (HD-ENH300) (.pdf)

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



Temporary Food Service Permit Application (.pdf)

Complete the Temporary Food Service Permit Application (.pdf) and submit at least seven (7) days prior to operating.



Tobacco Sale Registration and Permit Application (.pdf)

Complete the Permit to Sell or Distribute Tobacco Products Form (.pdf) in Dutchess County and return to DBCH.



Waiver Request Form (HD-160) (.pdf)

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



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

The Wastewater Disposal System Registration and Notice of Intent (SAN-36) Form (.pdf) is for homeowners and installers.



Water Operator in Responsible Charge Designation (DOH-4204) (.pdf)

The Designation of Water Operator in Responsible Charge (DOH-4204) Form (.pdf) is for owners/operators.



Water Well, Application to Construct or Abandon (SAN-35) (.pdf)

The Water Well, Application to Construct or Abandon (SAN-35) Form (.pdf) is for use by well drillers.