Illness Complaint Form

This form is to be filled out only if you or someone you know became sick from swimming. Print and fill out this form below, then mail to:

New York City Department of Health and Mental Hygiene
Office of Public Health Engineering
ATTN: Beach Program
42-09 28th St., CN-56
Long Island City, NY 11101

 

New York City Department of Health and Mental Hygiene
Bathing Beaches Monitoring Program
ILLNESS COMPLAINT FORM
 
 
Name: First ___________________________ Last _____________________________
Telephone #: (______) ______________________
E-mail address: __________________________________
If you're filling this form out for a child please check here.
Age of child: ______________________
If for an adult:
Gender: Male Female
Age: Under 18 18-35 35-50 50-65 65-80 Over 80
When did this illness occur? ____________________________________________________
Were there any of the following environmental factors present while you were swimming?
Check all that apply:
Dirty or murky water
Debris in the water
Oil or sewage in the water
Waterfowl (such as seagulls, ducks, geese)
Seaweed floating in the water
Other, please explain:
__________________________________
How would you describe the kind of contact you made with the water?
up to your knees up to your waist up to your neck over your head
How would you best describe your illness?
  (If you have chronic infections year-round please don't check.)
Check all that apply:
Ear infection
Eye infection
Sore throat
Stomach pains/Gastroenteritis
Pink itchy rash/Swimmer's itch
vomiting
diarrhea,
Other, please explain:
__________________________________
What is the name of the beach where you were swimming? (Please include town or city)
_______________________________________
Approximately how many people were in the water? _______________________________________
Were there any other people at the beach with similar symptoms? Yes No
Has this illness occurred more than once? Yes No
If yes, did it occur at the same beach or a different beach? same different
If it was a different beach, please give name and location ________________________________
Did you go to see a physician? Yes No
If yes, did they relate your illness to swimming? Yes No
Did you inform your doctor you were swimming? Yes No
Was this before or after they diagnosed your illness? Before After
How did they diagnose your illness? Please explain: ____________________________________
What was the doctor's name and location? (optional, however this information may help us with our future studies) ____________________________________

 

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