APPENDIX F
Mosquito Breeding Habitat Description

County: Town: __________________________

City/Village: Site: ____________________________

Location: ________

USGS Quadrant: GIS Coordinates: _______________

Inspection by: Date: _______________

Mosquito Breeding

Observed	Yes	No
Larvae Present
Pupae Present
Eggs Present

Number of larvae/dip:

_________________________

_________________________

_________________________

Site Description*
Environmental Setting:	Habitat Type:
Permanence of Habitat:	Habitat Condition:
Size:	Depth:
Remediation-Control Options*
Biological Control:	Water Management:
Chemical Control:	Spray Hazards:

*Accompanying sheet. Use more than one numerical code per category if necessary

Re-inspection by: Date: __________

Number of larvae/dip:

Remediation-Control Conducted: Yes No Method:_________________ Date:____________

Mosquito Breeding Habitat Description

New York State Department of Health Code Sheet for Mosquito Breeding Site Survey
ENVIRONMENTAL SETTING Business or Industrial Urban Suburban Farm Natural or Undeveloped Park or Recreational County, City, or Town Property State or Federal Property Other (describe)	HABITAT TYPE Salt Marsh Fresh Water Marsh, Swamp, or Bog Large Pond, Lake, or Ornamental Pond Small Pond, Pit, or Hole (TH=tree hole) Margin of Flowing Stream Ditch or Sluggish Stream Lg. Artificial Container (tank, boat, pool, etc) Sm. Artificial Container (tire, drum, barrel, etc) Other (describe)
PERMANENCE OF HABITAT Permanent – wetland, marsh, swamp Winter-Spring Pond Semi-permanent (water present more than 8 days after heavy rain) Transient or Temporary (water present less than 8 days after heavy rain) Stagnant, Land locked pond Mostly standing but with outlet, overflow, or movement Flowing Stream Tidal Other (describe)	HABITAT CONDITION *Use + or – for amount* Open water – no vegetation and bare shoreline Water polluted (oil, sewage, gas bubbles, film) Solid trash or debris in water (tires, cans, etc) Water clean or nearly so Woodland pool (no vegetation) Vegetation present Emergent Vegetation (CT-cattails, PH=phragmites) Floating Vegetation Much Marginal Vegetation 10. Other (describe)
REMEDIATION – CONTROL OPTIONS Environmental Sanitation Eliminate or Clean Filling or Grading Water Management Impounding Vegetation Removal Fish, Amphibians or Predaceous Arthropods Present Establish or Introduce possible biological control agents	CHEMICAL CONTROL Application of larvicides possible Accessible by truck Accessible by air only Application of adulticides No application of pesticides Water supply reservoir Swimming area Wetland Threatened or endangered species present Prohibited by owner or state/federal property Other (describe)

Weekly Miniature Light Trap Collection Form

Municipality: Area: _____________________________

Site: Month: _______________ Year: 20__

Genus species Name (Code)	Collection Dates				Total Females Per Week
	Day 1	Day 2	Day 3	Day 4
Ae. abserratus-punctor (ABP)
Ae. aurifer (AUR)
Ae. canadensis CAN)
Ae. cantator (CTT)
Ae. cinereus (CIN)
Ae. communis gr. (CGR)
Ae. dorsalis (DOR)
Ae. japonicus (JAP)
Ae. sollicitans (SOL)
Ae. sticticus (STC)
Ae. stimulans gr. (SEF)
Ae. taeniorhynchus (TAE)
Ae. triseriatus (TRI)
Ae. trivittatus (TVT)
Ae. vexans (VEX)
Ae. ____________
Ae. ____________
An. punctipennis (PUN)
An. quadrimaculatus (QUA)
An. walkeri (WAK)
An. ____________
Cq. perturbans (PER)
Cx. pipiens (PIP)
Cx. restuans (RES)
Cx. pipiens-restuans (PRE)
Cx. salinarius (SAL)
Cx. territans (TER)
Cx. ___________
Cs. melanura (MEL)
Cs. morsitans (MOR)
Cs. ___________
Ps. ___________
Ur. sapphirina (USA)
TOTAL

DOH FORM #TBA

CDC Gravid Trap and Egg Raft Collection Form

County:_______________ Site:______________________

Date:____________

Species	Number of			Parity			Number of
	NB	BG	Male	N	P	%P	Egg Rafts	Larvae
PIP
RES
SAL
PRE

Date:____________

Species	Number of			Parity			Number of
	NB	BG	Male	N	P	%P	Egg Rafts	Larvae
PIP
RES
SAL
PRE

Date:____________

Species	Number of			Parity			Number of
	NB	BG	Male	N	P	%P	Egg Rafts	Larvae
PIP
RES
SAL
PRE

DOH FORM #TBA

Laboratory Submission Summary Form

County Name: _______________ County Code: ______

Date to Laboratory: __________

Accession Numbers: From: ___________ To: ____________

Collection Dates: From: ___________ To: ____________

Number of Traps: ____ Total Number of Trap Nights: ____

Species Code	Number of		Accession Number		Results
	Pools	Specimens	From	To
Total

NOTES/COMMENTS:

DOH FORM #TBA

---

Summary of Miniature Light Trap Collections

Municipality: Area: ______________________

Collection dates: From:__________ To: __________

Genus species Name (Code)	Total Collected	Number of Trap-nights	Average per Trap-night
Ae. abserratus-punctor (ABP)
Ae. aurifer (AUR)
Ae. canadensis CAN)
Ae. cantator (CTT)
Ae. cinereus (CIN)
Ae. communis gr. (CGR)
Ae. dorsalis (DOR)
Ae. japonicus (JAP)
Ae. sollicitans (SOL)
Ae. sticticus (STC)
Ae. stimulans gr. (SEF)
Ae. taeniorhynchus (TAE)
Ae. triseriatus (TRI)
Ae. trivittatus (TVT)
Ae. vexans (VEX)
Ae. ____________
Ae. ____________
An. punctipennis (PUN)
An. quadrimaculatus (QUA)
An. walkeri (WAK)
An. ____________
Cq. perturbans (PER)
Cx. pipiens (PIP)
Cx. restuans (RES)
Cx. pipiens-restuans (PRE)
Cx. salinarius (SAL)
Cx. territans (TER)
Cx. ___________
Cs. melanura (MEL)
Cs. morsitans (MOR)
Cs. ___________
Ps. ___________
Ur. sapphirina (USA)
TOTAL

DOH FORM #TBA

Revised: May 2000

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