Forms & Applications

All applications and forms are to be turned in to your local health department. Contact your local health department with questions regarding these applications and forms. The Chickahominy Health District accepts cash, checks and VISA for fees associated with applications.

Food Service Applications, Forms, & Regulations
Name:	Description:
Food Establishment Application	Application for a Virginia Department of Health Food Establishment Permit
Foodservice Plan Review	Plans to review for approval before food establishment permit
FDA Food Establishment Plan Review Guide	Food and Drug Administration’s guide to assist food establishments in foodservice plan reviews.
Temporary Food Establishment Application Event Coordinator Application *These forms can be emailed to Chickahominy.EHSS@vdh.virginia.gov if $40 fee has been previously paid within the past calendar year.	Application for a temporary food establishment. Temporary event applications must be submitted 10 business days prior to an event
Virginia Food Regulations
FDA Federal Food Code Document	Food and Drug Administration’s guide to ensure food and public health safety from food establishments
Mobile Food Unit Application Mobile Unit Plan Review Document	Application for a Department of Health Mobile Food Unit Permit

 

Septic System Repair Malfunction Assessment and Instructions
Name:	Description:
Chickahominy Health District Septic System Repair History Questionnaire and Instructions *This form can be emailed to Chickahominy.EHSS@vdh.virginia.gov	Septic system repair instructions and repair history questionnaire
Malfunction Assessment
Septic System Repair Instructions
Freedom of Information Request Form	Form to request documents or other information under the Freedom of Information Act
VDH Septic System & Well Construction Permit Process	Information regarding hiring a private sector for construction permit process for wells or septic systems
Septic System and/or Private Well Application  Petition for VDH Services	Only owners that submit a petition for services and meet i) means testing requirements (household income does not exceed 100% of federal poverty guidelines), or ii) a hardship contained in the Virginia Department of Health’s Hardship Guidelines, will be eligible to receive evaluation and design services from the Virginia Department of Health.

 

Other Applications, Forms, & Regulations
Name:	Description:
Hotel Application	Application for a Department of Health Tourist Establishment/Campground/Summer Camp Permit
Summer Camp Application	Application for a Department of Health Summer Camp Permit
Campground Application Application for a Campground Plan Review	Applications for a Department of Health Campground Permit and Plan Review
Tourist Establishment Regulation
Migrant Labor Camp Application	Application for a Migrant Labor Camp Permit

 

Epidemiology Forms
Name:	Description:
EPI 1 Form PDF	Form to report disease cases to your local health department.
Electronic Morbidity Reporting Portal EPI1	EPI1 Portal Instructions
Electronic Morbidity Reporting Portal (EPI1)	EPI1 Portal

These documents are currently being remediated for accessibility. If you need assistance, please reach out to chdwellness@vdh.virginia.govH