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CCHD COVID-19 Large Gathering Event Notification Form

  1. Please complete and submit the following form for each event above the social gathering limit.
    Responsible Parties must submit event details to the local health authority, at least 5 days in advance of the event date, and such details shall include but not be limited to the (1) Responsible Parties’ contact information, (2) event name or function, (3) event address, (4) event date and time, (5) event duration (including loading and unloading times), (6) expected number of event attendees, (7) expected number of event staff, and (8) location on premises (e.g., indoor, outdoor) indicated by description and/or on event floor plan.
  2. Cortland County Department of Health (CCHD) is responsible for keeping this information on file and will NOT be contacting you unless there are compliance concerns. Events may be subject to inspection by local health authorities to ensure compliance with all provisions of the guidance. If you have any questions please refer to NYS INTERIM GUIDANCE, linked below. Thank you.
  3. Location Details
  4. **Food Service Facilities must have NY Forward Safety Plan completed and available for review**
  5. Please provide contact information of the individual who will maintain guest sign in (and table seating chart) for 28 days in the event contact tracing is required.
  6. The responsible party submitting this form must affirm below that all applicable current NYS COVID-19 Executive Orders and Guidance will be followed.
  7. Responsible Party*
    I am the responsible party for the business, organization or event listed. I have reviewed all applicable New York State interim guidance for event activities and operations during the COVID-19 public health emergency and I affirm that I have read and understand my obligation to operate this event in accordance with such guidance. I understand that my event may be subject to inspection by the Cortland County Department of Health to ensure compliance with all provisions of the guidance.
  8. Leave This Blank:

  9. This field is not part of the form submission.