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 
to download a free copy of this software.
Use the Application for Access to Dept. of Health Records - FOIL Form (.pdf) to request Freedom of Information Law (FOIL) access to DBCH records.
The Annual Water Quality Report Certification Form (.pdf) is used by water operators.
This application is for individuals who are requesting a letter for release from Quarantine/Isolation related to COVID-19.
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.
The Application for Approval of Plans for Public Water Supply Improvements (DOH-348) Form (.pdf) is used by engineers/licensed architects, operators.
Complete the Certificate of Waiver from Asbestos Sampling Requirement, Application for a (DOH-351) Form (.pdf) and return to DBCH.
The Certificate of Waiver from Disinfection Requirement, Application for (DCHD-350) Form (.pdf) is for use by owners/operators
The Certification of Construction Compliance (HD-159) Form (.pdf) is for use by engineers/licensed architects, operators.
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)
This form is to be used by owner/operator to Report Allegation of Abuse (.pdf) at a children's camp facility.
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.
The Injury Report Form (.pdf) is to be used by owner/operator to report an injury at a children's camp.
Complete the Community Event Request Form (.pdf) and return to DBCH.
Complete the Confidential Case Report (DOH-389) Form (.pdf) and return to DBCH.
The Consecutive Agreement Information (DOH-CAI) Form (.pdf) is for use by owners/operators.
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.
Use the Data Request Form (.pdf) - Electronic Submission (.pdf) to complete the form online and submit it electronically.
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.
The Deep Test Results (HD-185) Form (.pdf) is for plan approval documentation by engineers/licensed architects.
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.
The Engineering Report for Swimming Pool Plans (DOH-1309) Form (.pdf) is for use by engineers/licensed architects, operators.
The Engineer's Certification of Public Water Improvement Project Completion (DOH-5025) Form (.pdf) is for use by engineers/licensed architects, operators.
The Extension of Approval, Application for (HD-164) Form (.pdf) is for use by owners to request extension of expired or expiring approvals.
The Fill Section Certification (HD-5) Form (.pdf) is for plan approval documentation by engineers/licensed architects
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.
The Low Yield Wells Approval Application (WW-2) Form (.pdf) is for use by homeowners.
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.
The Percolation Test Results (HD-184) (.pdf) is for plan approval documentation by engineers/licensed architects.
Complete the Permit to Sell or Distribute Tobacco Products Form (.pdf) in Dutchess County and return to DBCH.
Application-for-Approval-of-Plans-for-a-Wastewater-Disposal-System.pdfThe Plans for a Wastewater Disposal System, Application for Approval of (HD-1) Form (.pdf) is for plan approval documentation by engineers/licensed architects.
Complete the forms and return to:
DBCH
Division of Weights and Measures
98 Peach Road
Poughkeepsie, NY 12601
Questions? Call 845-486-2949
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).
When a violation or situation occurs at a Public Water Supply, the Public Notification Certification Form ENH88 must be filed with the state within 10 days of notifying the customers documenting the event, the response to the event, and the notification of the public.
The Application for Public Water Supply Permit is for use by owners.
The Residential Sewage Disposal System, Application for Approval of (SAN-34) Form (.pdf) is for use by building inspectors.
The Sample Site Identification and Certification Form (.pdf) is for use by owners/operators.
The Sewer/Water Adequacy for New/Revised Use (HD-ENH300) Form (.pdf) is for use by business owners and operators.
Complete the Temporary Food Service Permit Application and submit at least seven (7) days prior to operating.
Complete the Permit to Sell or Distribute Tobacco Products Form (.pdf) in Dutchess County and return to DBCH.
Complete the Waiver Request Form (HD-160) (.pdf) for waivers from established codes and standards.
Complete the Waiver Request Form (HD-160a) (.pdf) for requests to modify required sampling or requests to change the treatment technique.
The Wastewater Disposal System Registration and Notice of Intent Form and Installers Guide is for homeowners and installers and includes guidance for the two step program and all forms.
The Designation of Water Operator in Responsible Charge (DOH-4204) Form (.pdf) is for owners/operators.
The Water Well, Application to Construct or Abandon (SAN-35) Form (.pdf) is for use by well drillers.
