Rhode Island Department of Health

The Mission of the Beach Monitoring Program is to protect the public from illnesses associated with swimming in contaminated bathing waters.

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Date / Time:
Beach:

Complainant Information
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zipcode:
Home Phone:	() -
Work Phone:	() -
Age:
Gender:
Occupation:

Complaint Details
First Symptom:
Last Symptom:
Number of Exposed:
Number of Ill:

Predominant Symptoms
:Nausea :Vomiting :How often / duration? :Diarrhea :How often / duration? :Fever ° F :Abdominal Cramps :Constipation :Fatigue :Skin :Other

Complainant Action Information
Physician Consulted: