Health Department Forms

The following is a list of downloadable forms sorted by individual departments. You may search from the search bar above or simply scroll through the list below. Many of the forms and documents here are also conveniently located on the service's subpages. If you do not see a particular form, please reach out to us for assistance.

COVID-19 Forms

The following are a list of downloadable and linked forms as it pertains to COVID-19

ECHD Records Requests

• ECHD Records Request Form
  This form can be used to request any public records from Environmental Health Services. You can submit this form digitally, by mail, fax, or it can be delivered in person.

Patient Services Forms

• Immunization Record Request Form (EN)
• Immunization Record Request Form (ES)

Health Education Forms

• Health and Wellness Program Descriptions
• Program Request Form
• Health Fair Request Form

• Volunteer Application
  Apply to Safe Kids Elkhart County to serve as a volunteer in preventing unintentional injuries.
• Fire Safety Checklist
• Fire Safety Checklist (Spanish)
• Water Safety for Kids
• Wheels Safety Checklist
• Wheels Safety Checklist (Spanish)

Environment Health Forms

• Swimming Pool Injury Report
• Daily Log Form
• Swimming Pool Signage
  List of required signs at public swimming pools.
• Pool Operator Info
  General information and reminders for public swimming pool operators
• Elkhart County Swimming Pool Ordinance
• Keeping Afloat
• Pool Plan Review Review Checklist

• Spill Packet
  This packet includes a list of clean-up contractors with the ability to respond to hazardous materials spills and a form that can be used to document spill reporting and clean-up response activities.

• Elkhart County Food Ordinance
• Food Service Self Checklist
  Food Service Operators can use this checklist as a self evaluation tool to promote and ensure safe food handling in their facilities.
• Home Based Vendor Guidelines
• Mobile Food Service Requirements
  Lists the minimum requirements that must be met to operate a mobile food service in Elkhart County.
• Consumer Advisory
• Certified Food Manager Law
• Sample Employee Health Policy
• Sample Employee Health Policy Questionnaire
• Not for Profit Registration Form
• Temporary Event Coordinator App
  Temporary Event Coordinators must fill out this application and submit by fax or mail at least 30 days prior to their event.
• Temporary Food Guidelines
  Guidelines for operating a temporary food service in Elkhart County.
• Food Safety News
• Plan Review Packet
  This packet will help prepare plans for constructing or remodeling a food service. Please follow the instructions carefully.

• IDEM Open Burning Brochure
  This brochure from the Indiana Dept. of Environmental Management explains the State's open burning law and gives alternatives to burning. A link to the current site is here.
• Conrail Superfund Site
  Provides information about the Conrail Superfund site in Elkhart and Saint Joseph Counties including location, contaminants, and answers to frequently asked questions. An older document of this can be found here.
• Groundwater Protection Ordinance
• Drinking Water Testing Labs
• Wastewater Characterization
  This is a list of laboratories or consultants capable of doing wastewater characterizations required by the Elkhart County Groundwater Protection Ordinance.
• GW Registration Brochure
  This brochure gives a brief overview of the Groundwater Protection Ordinance requirements and includes a registration form facilities can use to register with the Health Department.
• Application for Construction Permit

• Stop Raising Mosquitoes
  This pamphlet provides information on ways to reduce mosquito breeding sites around your home.
• Mosquito-Borne Diseases
  This pamphlet contains information about several diseases spread by mosquitoes.
• Ticks and Disease
  This pamphlet provides information about several species of ticks and the diseases they can carry.

• Application For Septic Permit
  This form is provided to show what information is required to apply for a septic permit. This form must be filled out in original and can be obtained at the Environmental Health Services Division office.
• Plan Submittal Checklist
  Checklist for Septic System Plan Submittal for New, Repair/Replacement Onsite Sewage Disposal Systems.
• Marking Utilities
  This is an information sheet concerning the marking of utilities before construction and soil evaluations/soil borings.
• ECHD Septic Ordinance Section 5
• Septic Lookup Request
  Use this form to request information on existing onsite sewage systems either by fax or by presenting to our office. Note: There is no information available for homes/addresses constructed prior to 1967.
• Sample "To Scale" Drawing
  "To Scale" drawings are required with all application submissions for an onsite sewage disposal system permit.
• Flood Dose Worksheet
  This worksheet must be submitted at the time of application when minimum requirements indicate a flood dose installation.
• Mound/Press Dist Worksheet
  This worksheet must be submitted at the time of application when minimum requirements indicate an elevated sand mound system or pressure distribution system installation.
• Onsite Evaluation Request
  Use this form to request an onsite evaluation/soil boring from ECHD for residences. This form can be completed at the ECHD Environmental Health Services Office or it can be printed and mailed or faxed to our office at (574) 875-3376.
• Septic System Care and Feeding B
  A guide from the EPA for the homeowner's care of their onsite system.
• Development standards
  Environmental Health Technical Review and Development Standards.
• Wastewater Treatment Matrix
  Wastewater Treatment Assessment Matrix
• ECHD Septic Ordinance - Ordinance No. 2012-153
  An ordinance regulating private sewage disposal systems in Elkhart County.
• Minimum Requirements
• Septic Permit Procedure Guide
  This guide explains the process for obtaining a private sewage disposal system permit, for new construction.
• Installer Registration Form
  This form is used to register septic installers in Elkhart County.

• Protect Your Family
  This pamphlet is an excellent resource. Landlords and sellers of homes, built before 1978, are required by law to present this pamphlet to the new owners or tenants to warn about potential lead hazards in the home. This law applies even if the landlord or seller has no specific knowledge about lead hazards in the home (English).
• Spanish Protect Your Family
  This pamphlet is an excellent resource. Landlords and sellers of homes, built before 1978, are required by law to present this pamphlet to the new owners or tenants to warn about potential lead hazards in the home. This law applies even if the landlord or seller has no specific knowledge about lead hazards in the home (Spanish).
• Lead Paint Safety A Field Guide
  This guide is part of HUD's approach to lead safety in the home. It will show you how to safely perform work around lead in a residence built before 1978 (English).
• Spanish Lead Paint Field Guide
  This guide is part of HUD's approach to lead safety in the home. It will show you how to safely perform work around lead in a residence built before 1978 (Spanish).
• Reducing Hazards during renovation
  This pamphlet is designed for contractors to help them determine what they can and cannot do when disturbing lead-based paint.
• Prerenovation Education Rule
  This brochure outlines the requirements for contractors, property managers, and others who perform renovations for compensation in residential housing that may contain lead-based paint.
• Property Manager Responsibilities
  This pamphlet is designed for landlords and apartment managers who are committed to providing a safe and habitable property for their tenants that complies with state and federal laws.
• New Indiana Habitability English
  This brochure details landlord obligations, liabilities, and disclosure rules for Indiana properties (English).
• New Indiana Habitability Spanish
  This brochure details landlord obligations, liabilities, and disclosure rules for Indiana properties (Spanish).
• EPA and HUD disclosure
  This brochure has questions and answers pertaining to federal lead disclosure laws.
• Lease Disclosure English
  EPA Title X requires landlords to disclose lead hazards by giving this form to tenants prior to leasing most residential homes built before 1978 (English).
• Lease Disclosure Spanish
  EPA Title X requires landlords to disclose lead hazards by giving this form to tenants prior to leasing most residential homes built before 1978 (Spanish).
• Sale Disclosure English
  EPA Title X requires sellers to disclose lead hazards by giving this form to buyers of most residential homes built before 1978 (English).
• Sale Disclosure Spanish
  EPA Title X requires sellers to disclose lead hazards by giving this form to buyers of most residential homes built before 1978 (Spanish).
• Finding a Qualified Lead Professional for Home
  This pamphlet will help you find a lead professional who will tell you if your home has lead paint in a form that may pose a hazard to your children.
• Lead Contractors and Home Testing
  This is a list of regional and local lead contractors and appropriate cleaning and home testing suppliers.
• Evaluating Homes for lead hazards
  This pamphlet is designed for the risk assessor, inspector, and clearance examiner so they understand their role in evaluating the property and their responsibilities and to better inform their clients.
• Lead- Who's at risk?
• Lead- Who's at Risk? Spanish
• Elkhart County Lead Elimination
• Consolidated Plan for Housing
• Participation Interest Form, HUD
  HUD Lead Grant Participation Interest Form

Vital Records Forms

• Birth Certificate Application (English)
• Birth Certificate Application (Spanish)