1. Email Address*

   Please enter your email and you will receive a copy of this clean up report.

2. 1. Group number

   Enter your group number if you know it, or leave blank if you're not sure.

3. 2. Date of clean-up (start date)
4. 2a. End date of clean-ups (if applicable)
5. 3. Name of Coordinator
6. 4. Name of group (if applicable)
7. 5. Site name
8. 5A.Local Government Area*
9. 6A. Number of participants - ADULTS
10. 6B.Number of participants - CHILDREN
11. 7. Approximate number of minutes at the site.*

    This number will be used to estimate total volunteer time at the site (if this report covers more than one clean-up event, please do a total of time at all clean-ups).

12. 8A. Were there any incidents or injuries to participants ? noyes
13. 8B. If yes give details.
14. 9. Number of orange litter bags filled
15. 10. Did you separate rubbish from recyclable litter items? YesNo
16. 11. How many of these bags were for rubbish only
17. 12. How many of these bags were for recyclable material only?
18. 13. If you picked up cigarette butts, please estimate how many? (otherwise skip this question)
19. 14. If you picked up used syringes, please record how many?(otherwise skip this question)

15. Did you pick up any of the following items (please tick for yes)

Aluminium cansglass bottlespaper/cardboardplastic bottles

20. 16. Other comments or unusual items found:

Photo use permission

I give KABC WA permission to use these photos in online and print publishing

21. Photos

* denotes a required field.