Public Records Request

public records request form

* Indicates required field

Name of Requestor *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Records Requested *

Method of Reciept *

Appointment to review record(s) before copying (between the hours of 8:00 am – 5:00 pm) (During Covid-19, This is not an option due to Visitor Restrictions in place) Photocopied 8½x11 via Mail Photocopied 8½x11 via personal pick-up (You MUST schedule your pickup in advance due to Covid-19 restrictions) Electronic Record(s) on USB thumb drive via mail Electronic Record(s) on USB thumb drive via personal pick-up. (During Covid-19 restrictions, you MUST schedule your pickup in advance)

Amount of associated fees due will be provided to the requestor prior to generating record(s). At the discretion of the District, electronic records may be provided via email as a PDF, after statement of associated risk is signed by requestor.

PLEASE READ CAREFULLY AND ACKNOWLEDGE UPON SUBMITTING REQUEST

The District will respond within five business days of receiving your public records request by: (1) providing the record; (2) acknowledging receipt of the request and providing a reasonable estimate of the time the District will be required to respond; or (3) denying the request.

Upon receiving the Records Request the District may ask for clarifying information in order to produce responsive records. *

I acknowledge

I may be charged as outlined in RCW 42.56.120. Request for Access to Public Records Policy. Please see our Public Records Request Policy in the link above. *

I acknowledge

I hereby declare, under penalty of perjury under the laws of the State of Washington, that if I have requested a list of individuals from Garfield County Public Hospital District No.1, the information obtained through this request will not be used of commercial purposes. • “A completed Commercial Purpose Declaration Form will be required.” • Post the updated GCHD Public Records Request form 2020 attached. *

I acknowledge

Submit