REQUEST FOR RECORDS
WEBER
-MORGAN HEALTH DEPARTMENT
Requestor’s Name: _____________________________________________________________
Address:
_____________________________________________________________________
City: ________________________________________ State: ___________ Zip:
____________
Daytime phone number where you can be contacted: ___________________________________
Clear description of record sought:
I
would like to inspect the record.
I would like to receive a copy of the record. I understand that the health department may
charge a fee for copies of records including staff time for
summarizing, collection, etc.
(§63-2-203, Fees), and that copies will be provided subject to fees being paid. I authorize
costs up to $______. If costs are greater than the amount specified, I understand that the
health department will contact me for approval prior to processing the request.
Requestor’s Signature_________________________________________ Date _____________
Request Accepted By _________________________________________ Date _____________
Request Processed By _________________________________________ Date _____________
Comments: ____________________________________________________________________
[
] Requestor notified that the office does not maintain the record. Date _____________
[
] Request for extension of time for extraordinary circumstances. Date _____________
[
] Cost authorization obtained from requestor. Cost $_________ Date _____________
[
] Cost waived. Approved by ____________________________ Date _____________
Record Accepted By _______________________________________ Date _____________
Fees Collected By _________________________________________ Date _____________
Comments ____________________________________________________________________
______________________________________________________________________________
WMHD 01/13
