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Public Health Contact Us Form

2. ¿No hablas inglés? Use el formulario en español para comunicarse con el departamento de salud pública.

4. Have questions about COVID-19 Vaccine? Visit our Vaccine page's Frequently Asked Questions or submit a question on our COVID-19 Vaccine form.

6. Disclaimer
   <ul> <li>Please do not submit confidential information, this form is not secure.</li> <li>Required fields are highlighted in pink and/or marked with a red asterisk.</li> </ul>

   • Please do not submit confidential information, this form is not secure.
   • Required fields are highlighted in pink and/or marked with a red asterisk.

8. Topic:*
   -- Select One --Air QualityBirth and Death CertificatesContact the DirectorDisease Investigation and DataEmergency PreparednessHealth Code and Regulations (Environmental)ImmunizationsInternships and VolunteersMediaOral Health ProgramsOther Clinical Services (TB, Hansens)Report a Problem (Mold, Mosquitoes, Insects)Restaurant / Food Establishment ConcernsSchools --- Infectious DiseasesSchools --- Nutrition, Physical Activity, Teen Pregnancy, and Tobacco PreventionSTD TestingStudent RequestsWomen, Infants and Children (WIC)Other

   Please select a topic from the list above that best reflects your area of concern.

10. First Name:*

11. Last Name:*

13. Email:*

14. Phone:*

16. City:

17. Zip/Postal Code:

19. Question/Comment:*

21. Response Deadline:
    Response Deadline:

22. Contact Me By:
    -- Select One --EmailPhoneNo Response Needed

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field