Records Request - Media request

Your full name, address, and contact information

Last name:

Your legal last name.

First name:

Your legal first name.

MI:

Your legal middle initial.

Street address

List your street address here.

City

List your city here.

State

Pick your state from the list below.

ZIP Code

List your ZIP Code here.

Phone number:

List your 10 digit phone number here.

Email address:

List your complete email address here.

Media outlet:

List the media outlet you are with (newspaper, magazine, radio, television station, etc. that you work for).

List the type of record or information requested:

List the type of record or information requested. For example:

"All APS and licensing inspection reports on (name of facility) for 2018"

"All Child Welfare records regarding (individual/client/child), specifically all foster parent records, screening reports and assessments" (For a high profile media case involving the death of a current or former foster child.)

"All DHS grants and contracts from (date range) with congregate care facilities, including BRS facilities"

"Children in Need of Placement data"

Reason for request:

List the date ranges for your records request:

Date From

Start of date range.

Date To

End of date range.

Select the preferred format to receive the record.

Mail

Pick up in person

USB flash drive

Request a Fee Waiver

Purpose for which the requesting party intends to use the information/records requested:

Specific ability (and plans) of requesting party to disseminate the information to the general public:

Explain how dissemination of the records/information requested will benefit the general public:

Please list any other information you feel would be valuable in evaluating fee waiver/reduction request:

File a complaint.

Show “Right to access your records” information.

For questions please contact: Email: DHS.RecordsRequest@dhsoha.state.or.us Fax: 503-581-6198

This document can be provided upon request in alternative formats for individuals with disabilities or in a language other than English for people with limited English skills. To request this form in another format or language, contact your local office. For a list of local offices please see https://www.oregon.gov/DHS/Offices/Pages/index.aspx.

To request this form in another format or language, contact the Publications and Creative Services at 503-378-3486, 711 for TTY, or email dhs-oha.publicationrequest@state.or.us

Provide the email address where you wish receipt of request to be delivered. If no email, please put na@na.com

Enter the email address where you wish correspondence related to this request to be delivered.

Enter the email address wher you wish correspondence related to this request to be delivered.

Re-enter the email address where you wish correspondence related to this request to be delivered.

Re-enter the email address wher you wish correspondence related to this request to be delivered.

v. 20191003

Form Version

Reference Code