FAIRFIELD DEPARTMENT OF HEALTH: DEPARTMENT FORMS

ENVIRONMENTAL HEALTH FORMS

• Nuisance Complaint Form
• Food Facility Review Packet
• Temporary Food Application Packet
• Mobile Food Application Packet
• Animal Bite Reporting Form
• Plumbing Forms
• Sewage Treatment Permit Application
• Variance Request Form
• Subdivision of Land / Lot Inspection Application
• Private Water System Application
• Well Pump Completion Form
• As-Built Packet
• Tattoo/ Body Piercing Facility Application
• STS Abandonment Form

NURSING FORMS

• TDAP & Menigitis Registration Forms for 7th & 12 grade
• ODH Reportable Disease Form
• ABC's of Reportable Diseases
• Adult Travel Paperwork  / Child Travel Paperwork
• Immunization Clinic Form

WIC PROGRAM APPLICATION + HEALTH HISTORY FORMS

• Welcome to WIC
• WIC Program Application /
   History Forms: Pregnant Woman, Breastfeeding & Postpartum Woman,
   Infants under 12 months, Children 1-5 years
• WIC Authorized Letter

SPANISH
WIC PROGRAM APPLICATION + HEALTH HISTORY FORMS

• Historial de Salud de WIC para Mujeres Embarazadas
• Historial de Salud de WIC para Infantes
• Historial de Salud de WIC para Niños de 1 hasta 5 Años
• Historial de Salud de WIC para Mujeres LactandoAmamantando y en Postparto

VITAL STATISTICS FORMS

• Application for Birth or Death Certificates