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Medical Privacy Complaint Form
The Privacy Officer will review your complaint within 10 business days
Your Name
*
First Name
Last Name
Your Phone Number
*
Format: 000-000-0000.
Your Email Address
example@example.com
SLCoHD Location Where Violation Occurred
*
Ellis R. Shipp Public Health Center (4535 South 5600 West, West Valley City)
Salt Lake Public Health Center (610 South 200 East, Salt Lake City)
Southeast Public Health Center (9340 South 700 East, Sandy)
South Main Public Health Center (3690 South Main Street, South Salt Lake)
South Redwood Public Health Center (7971 South 1825 West, West Jordan)
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Date of Violation
*
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Month
-
Day
Year
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Approximate Time of Violation
Hour : Minutes
AM
PM
AM/PM Option
Description of Violation
*
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