Records Request Form

Records Request Form

Please fill out each section completely and accurately.
In accordance with the Ohio Revised Code section 149.43, Franklin County Public Health is required to make records available for public inspection within a reasonable time period.

Immunization Records - For immunization records, complete the form on our website at https://myfcph.org/health-wellness/shots/.

Please note: In accordance with HIPAA, no personally medically identifiable information will be released via this records request. Only unidentified personal health or aggregate information will be released.

Franklin County Public Health does NOT have jurisdiction over the City of Columbus or the City of Worthington.

💡 If the property/business is located within the City of Columbus or the City of Worthington, do not complete this form. Instead, please visit https://www.columbus.gov/publichealth/About/Public-Records-Requests/ 💡
Requestor information
Today's Date *

Month Day Year
Requestor Name
Requestor Email
example@example.com
Requestor Phone Number

Area Code Phone Number
Requestor Company Name
Requestor Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Information requested
Description of Information Requested *
Be as specific as possible
Beginning Date of Information Requested

Month Day Year
Date
End Date of Information Requested

Month Day Year
Date
Address related to information request

Street Address

Street Address Line 2

City State

Zip Code
Attach Information or Documentation (if available)
Attach Information or Documentation (if available)
Your record will be released to you through the email you provided above. If you would prefer to receive the record by mail or if you prefer to pick it up, please provide those details here.
Confirm Request *
Should be Empty:

Records Request Form

Requestor information

Information requested