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County of Santa Cruz

Water Quality Monitoring Illness Report Form
Name
 		Age
Gender
 Phone Number/Email Address
Date of Exposure
 Time
Location
 Weather
Surf Condition
 Activity/Time in Water
Symptoms/Duration of Illness
 		Anything unusual about the water (color, odor, foam, dead organisms)
Previous Exposure to Other Water Bodies
 		Previous Exposure to Illness (family/friends)
Did you seek medical attention?
  
 
 

 

 

 

 

 

 

 

 

 

 
   
   
   
   
   
   
   
   
   
   
   

 

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