OHHABS Environmental Form

One Health Harmful Algal Bloom System (OHHABS) Environmental Form
Form Approved
OMB No. 0920-1105
Exp. Date: 11/30/2025

Environmental Form

One Health Harmful Algal Bloom System (OHHABS)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and
a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road
NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1105). DO NOT MAIL FORMS TO THIS ADDRESS

CDC REPORT ID

CDC FORM ID

STATE REPORT ID

REPORT DATE CREATED

GENERAL INFORMATION
Why was this characterized as a HAB event? (Select all that apply)
☐Bloom observed (e.g. by an individual, satellite imagery)
☐Associated animal illness(es)
☐HAB organisms/toxins detected via testing
☐Other (Specify) ________
☐Associated human illness(es)
Was this event associated with a benthic bloom or mat?
☐Yes ☐No ☐Unknown
Date bloom was first observed(MM/DD/YYYY): __________
How long did the bloom occur?
☐≤1 week
☐>3 months to ≤6 months
☐>1 year (ongoing)
☐Unknown
☐>1 week to ≤1 month
☐>6 months to ≤9 months
☐>1 month to ≤3 months
☐>9 months to ≤1 year
Date of initial notification to State, Tribal, Local, or Territorial Health Authorities(MM/DD/YYYY):__________
GEOGRAPHIC DESCRIPTION
LOCATION
State/Jurisdiction _______________
County(ies) ___________________
City(ies)/Town(s) _______________
Did the bloom impact Tribal or Federal lands?
☐Tribal Land ☐ Federal Land ☐ No ☐ Unknown
[If Tribal Land or Federal Land] Specify Name:__________
Did the bloom impact water in any other states/jurisdictions?
☐Yes ☐ No ☐ Unknown
[If yes] What other state(s) were affected? _______________
Official name of water body ______________
Common name of water body (if different) ______________
Specific location name __________________
LOCATION COORDINATES
Latitude:__________
Longitude:__________
☐Coordinates indicate an exact bloom location.
☐Coordinates indicate the affected waterbody
Hydrologic unit code (e.g., 04-Great Lakes) _______________
BLOOM DESCRIPTION
WATER BODY CHARACTERISTICS
What is the water type?
☐Lake/Reservoir/Impoundment
☐Ocean
☐Bay/Lagoon
☐Pond
What is the salinity of the water?
☐ Salt ☐ Brackish ☐ Fresh
What is the water body used for? (Select all that apply)
☐ Agriculture
☐ Aquaculture (e.g. fish, shellfish, aquatic plants, etc.)
☐ Industrial/Occupational (e.g., commercial fishing)
☐ Public drinking water system
☐ Raw/Non-potable water use (e.g. lawn care)

☐Coordinates indicate a routine monitoring location
☐Exact coordinates unknown
http://water.usgs.gov/GIS/huc.html

☐River/Stream
☐Other bodies of water (specifiy):__________
☐Unknown

☐ Recreation (e.g., non-commercial fishing, swimming, boating,
etc.)
☐ Other (specify) _______________
☐ Unknown

OBSERVATIONAL DATA
Date of
Who were these
Observation
observations
documented by?

Was was there
scum/algal matter
present?

What was the
color of the
water?

What was the
clarity of the
water?

Was there an
odor?

What was the
flow of the
water?

ADVISORIES
Does this water body have a history of blooms and/or HAB toxins?
☐Yes ☐ No ☐ Unknown
Were any advisory(ies)/warning(s)/notification(s) issued in response to the HAB event?
☐Yes ☐ No ☐ Unknown
Start Date (MM/DD/YYYY)__________
End Date (MM/DD/YYYY)__________
[If yes] Why was the advisory/warning/notification issued? (Select all that apply)
☐Bloom observed
☐Toxin/Biotoxin Detected
☐Human illness report/s
☐Cell counts
☐Animal illness report/s
☐Other (specify):__________
[If yes] Who issued the advisory(ies)/warning(s)/notification(s) ? (Select all that apply)
☐State/Local Health Department
☐Federal Agency (e.g., EPA, National Park Service)
☐State/Local Agency/Authority (e.g., Parks & Rec, Environment,
☐Other(specify)
Water, Fish & Wildlife)
☐Unknown
[If yes] Were any closures issued at water bodies or shellfish harvesting areas in response to the HAB event?
☐Yes ☐ No ☐ Unknown
[If yes] How was the public notified of the advisory(ies)/warning(s)/notificiation(s)? (Select all that apply)
☐Press release
☐Sign near the water
☐Press conference
☐Affected customers directly notified by their drinking water
☐Information posted on state or local government website
☐Other (specify) _______________
☐Social media posts (e.g., Facebook, X/Twitter)
☐Unknown
ENVIROMENTAL LABORATORY TESTING
Was testing conducted for algae, cyanobacteria, algal/cyanobacterial toxins, or components (metabolites/analytes)?
☐Yes ☐ No ☐ Unknown
[If yes] Which of the following was tested for algae, cyanobacteria, algal/cyanobacterial toxins, or components? (Select all that apply)
☐ Algae/Cyanobacteria/Phytoplankton
☐ Raw/Ambient water
☐ Finished drinking water
☐ Other (specify) __________
☐ Food/supplements (specify): __________
☐ Unknown
[If yes] Why was it tested? (Select all that apply)
☐ Fish illness/kill
☐ Monitoring
☐ Animal health event response
☐ Other (specify) __________
☐ Citizen complaint
☐ Unknown
☐ Human health event response
[If yes] What was it tested for? (Select all that apply)
☐ Algae/Cyanobacteria/Phytoplankton (organism)
☐ Fecal Coliforms
☐ Algal toxins/biotoxins
☐ Other (specify) __________
☐ Chlorophyll/Phycocyanin (pigment)
☐ Unknown
☐ Enterococci

ENVIRONMENTAL TESTING RESULTS (Please report each samples information individually)
Laboratory Result
1
2
Number

3

Result Detected?
Sample collection date
(MM/DD/YYYY)
Sample type
(e.g. water)
Classification (e.g.,
Cyanobacteria, Toxin,
Toxin-producing gene)
Genus or toxin
(e.g., Microcystis)
Species
(e.g., aeruginosa)
Sub-species
(e.g., f. scripta)
Concentration
(e.g., 20)
Concentration Unit
(e.g., ppm)
Test type
(e.g., ELISA)
ENVIRONMENTAL TESTING RESULTS REMARKS (Remarks should NOT include PII, CCI, other identifiers, webpage links, or additional location
information. Remarks should ONLY include information about the sample, test results, or other relevant laboratory
information.):_____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
GENERAL REMARKS (Remarks should NOT include any PII, CCI, other identifiers, webpage links, or lab/sample/testing information. Remarks should
only include relevant information not captured in the form.):______________________________________________________________________
________________________________________________________________________________________________________________________