1. 1. Group number

   This is your designated group number. Please email adoptaspot@kabc.wa.gov.au if you do not know yours

2. 2. Date of cleanup
3. 3. Name of Coordinator
4. 4. Name of group (if applicable)
5. 5. Site name
6. 6A. Number of participants- ADULTS
7. 6B.Number of participants-CHILDREN
8. 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)

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

17. 16. Other comments or unusual items found:
18. Photos
21. Email Address

    Please enter your email to receive a copy of this clean up report.

* denotes a required field.