Standing Water Monitoring Report Form

	Standing Water Monitoring Report Form We Need Your Help in the Fight Against West Nile Virus Is there standing water in your neighborhood that cannot be easily eliminated? If so, please provide us with the information requested below and a staff member from the Health Department will follow up on your report as soon as possible. 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. 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. All items marked with * are required fields for electronic form submission.
	StandingWater Reported By: (we may need to contact you for additional information)
	Your Name:
	Day Time Phone Number (e.g., (914) 995-1000):
	Evening Phone Number (e.g., (914) 995-1000):
	E-Mail Address:
	Your Street Address:
	City/Town/Village:
	State:
	Zip Code (e.g., 10601):
	Standing Water Information:
	*Date the standing water was first noticed (e.g., 03/09/2001):
	Type of Standing Water: (please select one)*
	If Other was selected, please specify:
	Location of Standing Water:
	The standing water is located at: (please select one)*
	If Public Property (please specify site name)
	If Other was selected (please specify site name)
	Owner or Resident's name of property with standing water (if known)
	Standing Water Address (if known):
	Standing Water City/Town/Village: (please select one)*
	Cross Streets/Between: and
	Standing Water Zip Code (e.g., 10601):
	Comments:( maximum 500 characters)
	If the above information is correct, click the Submit button to submit the Standing Water Report Form. If you need to make a change before you submit, click the Reset button below and start over.