256 Williamstown Road
Ottawa, OH 45875
Phone: 419-523-5608
Fax: 567-538-5076
Email: [email protected]
Website: www.putnamhealth.com
“Working towards a healthy and safe Putnam County”
Public Records Request
Person Requesting Record: __________________________________Telephone Number:_____________________
Requestor Address:________________________________________ Email/Fax#:____________________________
How would you like this information provided? ___Email ___Mail ___Pick up at Health Dept. ___Fax
Type of Record Requested:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Signature:____________________________________________________ Date:______________________________
*Signature required for release of records.
For PCHD Use Only
Date Request Received:____________________________________ Initials:________________
Date Request Fulfilled:_____________________________________ Initials:_________________
(copy sent, given to requesting individual, or individual notified document(s) ready for pick-up)
How was information Provided? ____________________________ _____Request Denied (see notes)
List Information Provided:____________________________________________________________________________
_________________________________________________________________________________________________
Notes:____________________________________________________________________________________________
