Form 20 E - Public Records Request Form
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1Public Records Request/Report
“Streamlined”
Public Records
✓ Child Care Center
Requestor Name _____________________________________________________________
Inspection Reports
Address ____________________________________________________________________
✓ Dairy Inspection Reports
City _______________________ State ________________ Zip Code _________________
✓ Drinking Water System
Telephone (____) _________________________ Fax (____) ________________________
Inspection Reports
✓ Food Service Establishment
Email Address ______________________________________________________________
Inspection Reports
Records Requested — (Please provide clear, concise description with dates, if applicable.
✓ Lists of
Attach a separate page if needed.)
●
Ambulance Services
____________________________________________________________________________
●
Dairy Farms
____________________________________________________________________________
●
Public Water Supplies
____________________________________________________________________________
●
Radioactive Materials
❑ Notify me if fee exceeds:
❑ $10
❑ $25
❑ $50
Handlers
●
Restaurants/Food Service
Establishments
Agency’s Response —
Records Never Open
Date
To Public Access
Request Received By _________________________________________
_________
(Including, but not limited to — )
✖ Applications For Licensure
Title __________________________ Location ____________________
❑ “Streamlined” Records Produced and Provided
✖ Complaints
✖ Personnel Files
(Send open records white copy to Communications)
Fee For Access ___________________
✖ Trade Secrets
Fee Collected By __________________________________________
_________
❑ Request Sent To Legal Staff By _______________________________
_________
Fees For Access
To Public Records
Legal Staff —
Whenever possible,
❑ Request Approved By _______________
The Health Department supplies
_________
❑ Request Denied By ________________________________________
(Send open records white copy to Communications)
public records at little or no cost.
_________
But the agency may charge
Reason __________________________________________________
_________
reasonable fees as follows to cover
_________________________________
(Send open records white copy to Communications)
cost:
❑ Records Produced And Provided By __________________________
$.25 per page . . copies
_________
Fee For Access ___________________
$10 per hour . . clerical assistance
❑ Requestor Informed By ____________________________________
$40 per hour . . technical or
_________
professional
❑ Fee Collected By _________________________________________
assistance
❑ Fee Closed By ___________________________________________
$50 per hour . . automated records
search
Comments __________________________________________
All Requests Must Be Submitted In Writing To —
(Either on this form or letterhead stationery)
___________________________________________________
Office of Communications
Mississippi State Department of Health
___________________________________________________
Post Office Box 1700
White Copy = Communications
Jackson, Mississippi 39215-1700
Yellow Copy = Requestor
Telephone 601-576-7667
Pink Copy = District/County/Office
Fax 601-576-7517
Mississippi State Department of Health
Revised 11-26-13
Form No. 20 E
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Parent category: Legal