New Jersey Department of Health and Senior Services

GOVERNMENT RECORDS REQUEST

IMPORTANT NOTICE: The second page of this form contains important information related to your rights to request government records. Please read it carefully.

REQUESTOR INFORMATION

(See Page 2 for important information)	PAYMENT INFORMATION
First Name:	MI:	Last:
Maximum Authorized Cost:
Company:
$
Mailing Address:
Selected Payment Method:
City:	State:	Zip Code:
Check Money Order
email Address:
Fees: Pages 1-10 @ $.75 per

Pages 11-20 @ $.50 per

Pages 21+ @ $.25 per

Delivery:	Delivery/postage fees additional depending upon delivery type.

Extras:	Extraordinary service fees dependent upon request.

Prepayment of fees required unless otherwise agreed.
Business Hours Telephone No.:	Ext.:
Preferred Delivery: Pick-up US Mail On-Site Inspection
Check One:

Under penalty of N.J.S.A. 2C:28-3, I certify that I HAVE / HAVE NOT been convicted of any indictable offense under the laws of New Jersey or any other state or the United States.
Signature:
Date:
RECORDS REQUEST INFORMATION

(To expedite your request, be as specific as possible.)

STATE USE ONLY
Estimated Document Cost:	$_____________

Estimated Delivery Cost:	$_____________

Estimated Extra Cost:	$_____________

Total Estimated Cost:	$_____________

Deposit Amount:	$_____________

Estimated Balance:	$_____________

Deposit Date:	_______________________	Disposition Notes: (Custodian: If any part of request cannot be delivered in 7 days detail reasons here.)

In Progress-Open	__________

Denied-Closed	__________

Filled-Closed	__________

Partial-Closed	__________	Tracking #:	_________	Finalized Cost:

Rec’d Date:	_________

Ready Date:	_________	Total	$_________

Total Page:	_________

Deposit	$_________

Documents Provided:

____________________	Balance Due:	$_________

____________________	Balance Paid:	$_________

____________________

____________________	______________________

(Custodian Signature)

____________________

Date: _________________
OC-34

JUL 02

PUBLIC ACCESS TO GOVERNMENT RECORDS

1.	State Law requires that in order to request access to government records, you must complete, sign and date this request form and deliver it in person, by mail or electronically during regular business hours to the appropriate custodian of the requested record. The New Jersey Department of Health and Senior Services will not accept submission of a request form by fax. Until the appropriate custodian, of the requested record, has received the Government Records Request form, your request is not considered filed. If you submit the request form to any other officer or employee of the New Jersey Department of Health and Senior Services, that officer or employee does not have the authority to accept your Government Records Request form on behalf of the New Jersey Department of Health and Senior Services and you will be directed to the appropriate division custodian. Descriptions of the divisions and agencies of the New Jersey Department of Health and Senior Services can be found at www.state.nj.us/health/index.html.

2.	If you submit a request for access to government records to someone other than the appropriate custodian, do not complete the Government Records Request form in full, or attempt to make a request for access by telephone or fax, the Open Public Records Act and its deadlines, restrictions and remedies will not apply to your request.

3.	The fees for duplication of a government record in printed form are listed on the front of this form. We will notify you of any special charges, special service charges or other additional charges authorized by State law or regulation before processing your request. Payment shall be made in check or money order, payable to the “State of New Jersey.”

4.	Anonymous requests, when permitted, require a deposit of 100% of estimated fees. You agree to pay the balance due upon delivery of the records.

5.	By State Law, a custodian must deny access to a person who is convicted of an indictable offense in New Jersey, any other state, or the United States, who is seeking government records containing personal information pertaining to the person’s victim or the victim’s family.

6.	By law, the New Jersey Department of Health and Senior Services must notify you that it grants or denies a request for access to government records within 7 business days after the custodian, of the requested record, received the request, provided that the record is currently available and not in storage or archived. If the requested record is not currently available or is in storage or archived, the custodian will advise you within 7 business days when the record can be made available and the estimated cost. You may agree with the custodian to extend the time for granting or denying your request or making records available.

7.	You may be denied access to a government record if your request would substantially disrupt agency operations and the custodian is unable to reach a reasonable solution with you.

8.	If the New Jersey Department of Health and Senior Services is unable to comply with your request for access to a government record, the custodian will indicate the reasons for denial on the Government Records Request form and send you a signed and dated copy.

9.	Except as otherwise provided by law or by agreement with the requestor, if the custodian of the requested record fails to respond to you within 7 business days of receiving a written, signed request form, the failure to respond will be considered a denial of your request.

10.	If your request for access to a government record has been denied or unfilled within the time permitted by law, you have a right to challenge the decision by the New Jersey Department of Health and Senior Services to deny access. At your option, you may either institute a proceeding in the Superior Court of New Jersey or file a complaint in writing with the Government Records Council (GRC) located in the Department of Community Affairs. You may contact the Government Records Council by telephone at 866-850-0511. The GRC’s web site is www.nj.gov/grc/.

11.	Information provided on this form may be subject to disclosure under the Open Public Records Act.

Elaine White

2002-07-03

NJDHSS