Woman completing a Regional Municipality of Durham online form on a computer.

Form Builder

Home Health and Wellness Illness, Infection and DiseaseWest Nile Virus

Required fields are marked with asterisks (*)

Apply for Catch Basin Larviciding on Private Property

By completing this form, you acknowledge and understand:

You are agreeing to be contacted by email.
Sharing of personal and/or personal health information via email should be kept to a minimum.
Any personal and/or personal health information that you provide to us via email will only be used to respond to your message and/or provide you with the requested information.
While steps are taken to protect the privacy and security of emails, sending and receiving emails over the internet is not secure. We cannot guarantee the security of any messages sent or received.
Your information may be used internally for planning, evaluation and program improvement purposes.
You may withdraw your consent to the use of email at any time by contacting us.
Do not use email for emergency or urgent health care matters.

Property and owner information

Owner's first name:

Owner's last name:

Property address:

Postal code:

Phone number:

Email address:

Do you need to be present for the larviciding treatment?

Yes

Catch basin information

You can upload a maximum of two (2) photos per catch basin. Our system is unable to process/accept files larger than 3MB. If the photos you are attempting to send us are greater than 3MB, you will need to reduce the file size prior to uploading them through our online form.

Please descibe the location of the catch basin on the property

If possible, please upload a photo showing the catch basin

Browse…

Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Add catch basin Remove catch basin

Confirm authorization

I verify that I am the registered owner of the above property and as such, have the legal authority, the necessary power, and capacity to request and authorize larviciding on the catch basins on the above property.

Agree

Personal Information is collected under the authority of the Health Protection and Promotion Act R.S.O. 1990 c.H.7, s. 5 (as amended). This information is collected and used for the purpose of preventing, eliminating and/or decreasing the effects of a health hazard. Questions about this collection and use of information should be addressed to Durham Region Health Department, Manager, Health Information, Privacy and Security at 605 Rossland Rd E., P.O. Box 730, ON, L1N 0B2, (905) 668-7711.