Standing Water Monitoring Report Form : West Nile Virus : NYC DOHMH

The New York City Department of Health and Mental Hygiene

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Standing Water Monitoring Report Form : West Nile Virus : NYC DOHMH

West Nile Virus

Standing Water Monitoring Report Form

The Department of Health & Mental Hygiene is now accepting reports of standing water. However, we will not be able to visit and treat all reported nuisances. Therefore we are encouraging City residents and business owners to take immediate action to eliminate standing water on their property.

For additional reference, please refer to Reducing Mosquitoes around your Home and community fact sheet.

Directions: Enter all information requested below by typing on the computer keyboard in the available spaces. Use the Tab button to move from box to box or use your mouse to point and click. Use your Space Bar to make checks within the boxes. After all of the information is entered, use the Submit button at the bottom of the page to submit the Standing Water Monitoring Report form.

Please fill out the following information. This information will be kept strictly confidential.

Standing Water Reported by:

Full Name:
Street Address:
City:
State:
Zip Code:
Day Phone:	*
Evening Phone:	*
Cellular Phone:
E-mail Address:

* The Department of Health and Mental Hygiene may need to contact you to verify the details of your report. If you do not provide your phone number, the Department of Health and Mental Hygiene may not be able to take action on your report.

Location of Standing Water:

Address or Street Name:
Cross Streets / Between:	&
Borough:
Zip:
If public site, provide name (i.e. Prospect Park):

Special Instructions:

Please provide any information that would assist our efforts to locate the standing water.

Standing Water Information:

Date the Standing Water was first noticed:

Note: If you are reporting standing water that is due to a sewer back-up, clogged storm drain, a leaking fire hydrant or water coming up from the ground or street, please call the Citizen Service Center at 311. For all other types of standing water, please continue to fill out this form.

Comments:

If the above information is correct, use the Submit button to submit the Standing Water Report form. If you need to make a change, you can hit the Start Over button below to erase all of the information entered.

For more information about West Nile virus, call the New York City Department of Health and Mental Hygiene at 311; or check our Web site at nyc.gov/health.