Your full name, address, and contact information

Your legal last name.

Your legal first name.

Your legal middle initial.

List your street address here.

List your city here.

Pick your state from the list below.

List your ZIP Code here.

List your 10 digit phone number here.

List your complete email address here.

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

Program holding records (check all that apply)

Program holding records. Check all that apply.

If you checked "Other(s) or unknown" above, describe here. Name the program(s) here or what you mean by "unknown." For example, "Oregon Health Plan records," or "I was in a DHS program two years ago, but I don't remember the name."

If you checked "Other(s) or unknown" above, describe here. Name the program(s) here or what you mean by "unknown." For example, "Oregon Health Plan records," or "I was in a DHS program two years ago, but I don't remember the name."

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"

List the date ranges for your records request:

Start of date range.

End of date range.

Select the preferred format to receive the record.

Request a Fee Waiver

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 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 wher you wish correspondence related to this request to be delivered.

v. 20191003

Department of Human Services