Clean-up Reporting Form

Clean-up Reporting Form

Parks & Recreation
Please Note
- Notify the Volunteer Coordinator with the location of bags from cleanups within two days of each clean-up.
- Group the trash bags together, and when practical, place them at least 8 feet from the side of the road to make the job of collecting bags easier and safer.
- Always be aware of your surroundings.
- Please report any unknown substances or possible hazardous materials by calling 9-1-1. Give a brief description of the problem and the nearest physical address to the problem (street name and block number).
- DO NOT attempt to clean unknown substances; they can be hazardous to your health
Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes Chapter 132, their e-mail address is considered public record.
Primary Contact Information
Date of clean-up*

MonthDayYear
Date
Name of group/organization
Email*
example@example.com
Name of clean-up site*
Bag Location (old)*

Street Address

Street Address Line 2

CityState

Zip Code
Location of bags/debris to be picked up (closest corner)*
E.g.,Northbound corner of North Ave. and East St.
Number of bags collected*
Debris removed (i.e. tires, paper, plastic, etc)*
Number of adult participants*
Actual number of hours spent doing the clean-up*
Number of youth participants (under age 18)*

RATING AREA ASSESSMENT
- Rate the area 1 through 5 stars: 1 meaning the area needs immediate attention and 5 meaning the area is excellent.
- Please note if anything looked unnatural or out of the ordinary during your visual inspection.
General items (ie. benches, tables, signage, graffiti)
General items (ie. benches, tables, signage, graffiti)
Improvements/Comments
Playground equipment, basketball court
Playground equipment, basketball court
Improvements/Comments
Shelters/Rooms (ie. restrooms, sidewalks, roofing, etc.)
Shelters/Rooms (ie. restrooms, sidewalks, roofing, etc.)
Improvements/Comments
Environmental (ie. creeks, creeks banks, poisonous plants, bees/hornets, insects, wildlife, etc. )
Environmental (ie. creeks, creeks banks, poisonous plants, bees/hornets, insects, wildlife, etc. )
Improvements/Comments
YesNo
Improvements/Comments
TRAILS ONLY Trail markings, signage, etc
TRAILS ONLY Trail markings, signage, etc
Improvements/Comments
Should be Empty:

RATING AREA ASSESSMENT