Public Health Contact Us Form

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

4. 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.

6. 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.

8. First Name:*

9. Last Name:*

11. Email:*

12. Phone:*

14. City:

15. Zip/Postal Code:

17. Question/Comment:*

19. Response Deadline:
    Response Deadline:

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

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22. 1. Receive an email copy of this form.
23. Email address

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24. Submit

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