Utah Department of Administrative Services

Division of Archives & Records Service

County Schedule 25 Local Health Records

 

Contents

 

ALIVE AND WELL PROGRAM CASE FILES (Item 25-1)

These case files document participation in the Alive and Well Program. It is an educational program run by local health departments to encourage people to live healthier life-styles by preparing a health risk appraisal and fitness profile. The files include the informed consent and release form, physical activity readiness questionnaire, health risk appraisal, nutritional, and screening answer sheet. This program is also called Healthy Heart Program or the Healthy Lifestyle Program.

Retention

Retain for 2 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

ANNUAL PROGRAM REPORTS (Item 25-100

These are annual reports on public health programs administered by the local department. They are used to track programs and employee time. They are compiled from the Quarterly program reports. The reports include time spent, number of people seen, names and ages of person served, and sometimes descriptions of program.

Retention

Permanent. May be transferred to the State Archives.

Suggested Primary Designation

Public.

(Approved 01/96)

 

BIRTH AND RELATIONSHIP VERIFICATION (Item 25-2)

This request is submitted by the State Division of Family Services to local registrars to search birth records. Since some people cannot afford to obtain birth certificates, it is used to verify births and relationships to receive state benefits. The form includes father's name, an indication which other forms were also completed (acknowledgment of paternity of parents, paternity of father and date, or paternity not acknowledged), mother's name, name of children, birthdate, place, certificate numbers, signature and title of local health official.

Retention

Retain for 2 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

BIRTH CERTIFICATES (Item 25-3)

These certificates document all live births in the State of Utah in compliance with UCA 26-2-5 (1995). In 1905, a state registry system of vital statistics was established at the State Health Department with local registrars. All certificates created prior to 1905 are only maintained at the local level and prior to 1978 some local registrars may not have reported all births to the State Health Department. Since 1978, all certificates maintained at the local level are duplicate certificates maintained by the State Health Department. The information recorded includes the child's name, place of birth, date of birth, sex, and if child part of multiple birth; the parents' name, race, age, birthplace, occupation, and marital status; a record of children previously born to the mother; the length of the pregnancy; the child's weight and length at birth; the date of the serological test; and a description of any congenital malformations or birth injuries.

Retention

Permanent. May be transferred to the State Archives.

Suggested Primary Designation

Exempt:UCA 26-2-22 (2008).

(Approved 12/92)

 

BLOOD PRESSURE/CHOLESTEROL RECORDS (Item 25-4)

These records are a two-part form completed by health workers for clients having blood pressure and cholesterol health screenings. These informal screenings are held at various locations throughout the district including shopping centers and health fairs. They are used to identify existing health problems and to encourage healthy lifestyles. The original (white copy) is submitted to the State Bureau of Chronic Disease Control and is maintained as the record copy while the yellow copy is retained by the local health department. The form includes the name, address, social security number, phone number, weight, height, birth date, age, gender, ethnic origin, education level, questions concerning smoking, questions concerning blood pressure and blood cholesterol, brief family and individual medical history, blood pressure readings, blood cholesterol readings and signed consent authorizing blood pressure and cholesterol tests.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

BOARD MEMBER APPLICATION (Item 25-5)

This is an application used to apply for a position on the local board of health. All applications are retained for two years to create a pool for possible future openings. The form includes name, address, business and home telephone numbers, education and work experience in health and environmental fields, volunteer experience, reasons for wanting to serve on board, occupation, signature and date.

Retention

Retain for 2 years after appointment is made and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

Board of Health Minutes (Item 25-6)

Please refer to the state schedule for Open Meeting Minutes and Public Materials. SG 1-59

 

BURIAL-TRANSIT PERMIT APPLICATION (Item 25-7)

This application is used to obtain a permit to allow the removal of burial remains in accordance with UCA 26-2-17(3) (1995). It includes death certificate number, deceased's name, birth date, birth place, death date, place of death, name of next of kin or other person authorizing disposition, disposition (burial, cremation, or other), funeral home, address, license number, name of person issuing permit, date issued, registrar's signature, how body was disposed (burial, cremated, other), date permit issued, cemetery name, place, county, state, and signature of person in charge.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

CAPITAL OUTLAY DETAIL STATEMENT (Item 25-8)

This is a monthly report submitted by the local health department to the state Department of Health listing the amounts spent for capital outlay on state contracts. It includes the local health department's name, the reporting period, payee's name, the contract or program where the outlay was made, and expenditure amount.

Retention

Retain for 3 years or after state audit and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

CAR SEAT RENTAL AGREEMENTS (Item 25-9)

These contracts document the rental of car seats to individuals who choose not to buy their own. This program enables those individuals to comply with UCA 41-6-148.20 (1995) which requires the use of child restraint devices. These contracts include the car seat number; the return date; the name, address, telephone number, drivers license number, and borrower's signature; the names and addresses of two individuals who will know the whereabouts of the borrower; a parental checklist that the borrower received training in the use of the car seat and that the seat was inspected; the amount paid; the dates issued and due; the seat condition when issued; and the receipt number. Some local health department also sell car seats.

Retention

Retain for 4 years after the expiration of the contract and then destroy (UCA 70A-2-725 (1995)).

Suggested Primary Designation

Public.

(Approved 12/92)

 

CASE MANAGEMENT FILES (Item 25-10)

These files, required by 42 CFR 441.56(a) (1992), are used by the health department to ensure that all individuals who are eligible to enroll in the Medicaid program are notified; and to determine eligibility of individuals accepted into the program. These files include the case management form, recipient list, and screening notifications.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

CERTIFIED BIRTH CERTIFICATE AND BIRTH CARD APPLICATION (Item 25-11)

This application form is used to request a certified birth certificate or birth card. It includes the name, date of birth, and city of birth of the individual whose birth certificate is being requested; the applicant's name, address, telephone number, and relationship to the individual whose birth certificate is being requested; the name, year, and state of birth of the individual's parents; reason for the request; request date; and the number of copies of the birth certificate or card requested.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

CERTIFIED DEATH CERTIFICATE APPLICATION (Item 25-12)

This application is used to request a certified death certificate. It includes identifying information, death date, deceased's name, place of death, county birthplace of decedent, usual residence of decedent, name of father, mother, reason for requesting including relationship to person whose certificate is requested, signature of applicant, address, phone, date, number requested, and fee amount.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

CERTIFIED EMISSIONS MECHANIC PERMIT APPLICATIONS (Item 25-13)

These files document mechanics certified as being qualified to conduct emission inspections. They include the applicant's name, address, and home telephone number; applicant's employer; business telephone number and address, applicant's signature; date the application was approved; date the permit was issued; permit number; fee amount; and expiration date.

Retention

Retain for 2 years after permit has expired or been terminated and then destroy.

Suggested Primary Designation

Public.

Suggested Secondary Designation

Private:applicant's home address and telephone number

(Approved 12/92)

 

CHILD HEALTH CASE FILES (Item 25-16)

These case files document the participation of children in the Child Health Evaluation and Care Program (CHEC). This is a low cost program to identify public health problems and to promote healthy children in low income families ineligible for Medicaid. They include the child health record, well child care 4-5 years of age form, and well child care examination forms. These records are also called Well Child case files.

Retention

Retain until child reaches the age of 21 and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

CHILD HEALTH EVALUATION CARE (CHEC) TARGET AREA RECORDS (Item 25-14)

These records are consent and release forms distributed by the Children Health Evaluation Care (CHEC) program. Each local health department determines concentration areas and groups to be targeted. This form is used to notify parents within targeted groups of the services provided and to identify infants eligible for the program. These records include both originals and duplicates. The form includes an explanation of the CHEC program, a statement on confidentiality of personal information collected, a statement allowing for the release of information for follow-up purposes containing the date, parent's name, address, telephone number, signature, birth date, social security number, marital status, and number of children.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

CHILD HEALTH EVALUATION CARE MEDICAID REIMBURSEMENT REPORT (Item 25-15)

This form reports the reimbursements received on claims for physical examinations provided under the Child Health Evaluation (CHEC) program. A Medicaid billing form is submitted for each completed examination and the original is submitted to the Utah Medical Assistance Program (UMAP) for reimbursement. This form includes child's name, date service provided, date into program, home address, phone number, medical information and patient identification number.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

CHILD HEALTH EVALUATION CARE SCREENING RECORDS (Item 25-17)

These files document services provided to children accepted in the Child Health Evaluation Care (CHEC) program as part of the Medicaid program. The purpose of the screening is to examine and evaluate the general physical and mental health, growth, development, and nutritional status of Medicaid recipients under the age of 21 and to provide corrective treatment. These files include the screening evaluation, claim forms, child health conference evaluation forms, progress form, history form, immunizations, assessment forms, Medicaid records, and growth charts.

Retention

Retain until child reaches the age of 21 and then destroy.

Suggested Primary Designation

Private.

Suggested Secondary Designation

Controlled:mental health screenings

(Approved 12/92)

 

CHILDREN'S SPECIAL HEALTH SERVICES CLIENT FILES (Item 25-18)

These client files document services provided to handicapped children through various clinics such as pediatric assessment, orthopedic, neurological, cardiac, orofacial, etc. The records are transferred from local health departments to the state and back depending on clinic location. After case is closed the client file is transferred to the State Health Department. The client files include a face (summary) sheet, release of information form, application for services form, registration form, an authorization for service form, referral for services form, clinic physician's recommendation form, clinic summary and rescheduling form, progress notes, growth charts, questionnaires for parents or guardians, food record, and a client medical questionnaire.

Retention

Retain until case closed and then transfer to State Health Department.

Suggested Primary Designation

Private.

(Approved 12/92)

 

COMMUNICABLE DISEASE CASE FILE INDEX (Item 25-19)

This is an index of easily accessible basic patient and statistical information regarding reportable communicable diseases. As stated in the Utah Code of Communicable Disease Rules, the information enables the Department to protect the public health, and prevent and control disease. Includes patient's case number, name, address, race, sex, and age; report source and date reported; onset date of the disease; attending physician; patient's hospital; lab results; disease specification of type, if applicable; and date the form was sent to Center for Disease Control, if applicable. Some of the diseases include amebiasis, ascariasis, botulism, campylobacter, cocciodomycosis, and Colorado tick fever. The State Bureau of Epidemiology maintains the record copy of these records permanently.

Retention

Retain for 7 years after case closed and then destroy.

Suggested Primary Designation

Exempt:UCA 26-25a-101 (2008).

(Approved 12/92)

 

COMMUNICABLE DISEASE CASE FILES (Item 25-20)

These files are kept in order to maintain a concise, accurate, and historical record of reportable communicable diseases and epidemiological investigations. As stated in the Utah Code of Communicable Disease Rules, the reports enable the Department of Health to protect the public health, and prevent and control communicable disease. Includes investigations such as Botulism Alert Summary, Reyes Syndrome Case Investigation Report, Leprosy Surveillance, Outbreak Investigation, Infant Botulism, Pertussis Report, and Weekly Campylobachter Surveillance Report; also includes original incoming and copies of outgoing correspondence related to epidemiological investigations. The State Bureau of Epidemiology maintains the record copy of the records permanently.

Retention

Retain for 7 years after case closed and then destroy.

Suggested Primary Designation

Exempt:UCA 26-25a-101 (2008).

(Approved 12/92)

 

COMMUNICABLE DISEASE CONTROL PROGRAM FILES (Item 25-21)

This is a record of incoming and outgoing correspondence, related to the Communicable Disease Control Program. Includes financial, medical, disease control, and patient information; policies, procedures, rules, regulations, ordinances; and general program operational files. The State Bureau of Epidemiology maintains the record copy of these records.

Retention

Retain until updated or superseded and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

CONTRACTS (Item 25-22)

These are contracts between local health departments and the State Health Department. They document agreements between the state and local departments to operate specific programs. The State Health Department re-grants federal funds and grants state funds under certain requirements stated in the contracts.

Retention

Retain for 6 years after expiration of contract (UCA 78-12-23 (1995)) and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

DAY CARE LICENSING PUBLIC HEALTH NURSE REVIEW RECORDS (Item 25-23)

This inspection form documents the separate annual review of day care centers by public health nurses prior to their state licensing and the relicensing. The form includes center's name, address, owner and person in charge; visit date, arrival and departure times, public health nurse's signature, department's name, indication of review of program and records, and recommendations and comments.

Retention

Retain until facility no longer licensed and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

DEATH CERTIFICATES (Item 25-24)

These death certificates document all deaths occurring in the State of Utah as required by UCA 26-2-13 (1995). In 1905, a state registry system of vital statistics was established at the State Health Department with local registrars. All certificates created before 1905 are only maintained at the local health department and prior to 1978 some local registrars may not have reported all deaths. Since 1978, all originals are maintained at the State and copies at the local level. The information recorded includes the deceased's name, gender, date of birth, race, age, county of death, address, birth place, citizenship, marital status, name of spouse, social security number, occupation, and parents' names; cause of death; if an autopsy was taken; if accident, suicide, or homicide caused death; place and time of death; disposition of the body; name and address of mortuary or crematory; and signature of person certifying death.

Retention

Permanent. May be transferred to the State Archives.

Suggested Primary Designation

Exempt:UCA 26-2-22 (2008).

(Approved 12/92)

 

DEATH HOLD BOOK (Item 25-25)

This book serves as a tracking device recording the status of death certificates. Death certificates are required to be filed prior to the funeral, but if this is not possible the mortuary will notify the local registrar and receive a hold number. This book is used to verify that death certificates were finally received. It includes hold number, death date, decedent's name, physician, funeral director, decedent's age, burial date, city of death, date hold number issued, date received, number of copies issued, whether the death certificate is pending and whether or not a burial transit was issued.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

DETAIL COLLECTIONS STATEMENT (Item 25-26)

This is a monthly statement sent to the Department of Health reporting the amount of fees collected by the local health departments from patients or clients on state contracts. This statement includes the local health department name, month, the allocation of collections by contract or program type, the type of collection (vital statistics, patient fees, etc.), the amount of the collections, and the total amount collected.

Retention

Retain for 3 years or until state health department audit and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

DISINTERMENT PERMIT (Item 25-27)

This permit allows for the disinterment of burial remains from a cemetery. The form includes county, city, date permit issued, applicant's name, deceased's name, age, sex, place of death, death date, cemetery or city from and to, next of kin signature, permit number, and signature of local registrar at disinterment.

Retention

Permanent. May be transferred to the State Archives.

Suggested Primary Designation

Public.

(Approved 12/92)

 

DRINKING WATER SYSTEMS SURVEY (Item 25-28)

These surveys record the inspections of water tanks for proper security, sanitation, proper maintenance, sanitation, and chlorine levels to guarantee water quality. The survey forms include date, name and address of owner, location of water system, results of inspection, and signature of sanitarian.

Retention

Retain until system is no longer in operation and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

EMERGENCY RESPONSE HAZARDOUS WASTE CASE FILES (Item 25-29)

These case files document the investigation of hazardous waste incidents including the cleanup, the process and the proper waste disposal. The case files include complaint date, time, and number; complainant's name, address, and telephone number; spill location; material spilled; weather conditions/local terrain; time on scene; population area; personnel on scene; volume of spill; anticipated movement of spill; action taken; water bodies or streams involved; name of shipper/manufacturer; chemical placarding/labeling information; container type; railroad/truck ID number; injury or exposure; samples taken; and signature of registered environmental health specialist.

Retention

Permanent. May be transferred to the State Archives.

Suggested Primary Designation

Public.

Suggested Secondary Designation

Protected:trade secrets, confidential informant information

(Approved 12/92)

 

EMPLOYEE CONFIDENTIALITY AGREEMENTS (Item 25-30)

This agreement is signed by the employee and maintained by the department stating that the employee will not disclose confidential information in accordance with UCA 26-25-4 (1995). The agreement usually becomes part of the employee's official personnel file. It includes the terms of the agreement, the date, employee's signature, and supervisor's signature.

Retention

Retain until final disposition of personnel file and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

ENVIRONMENTAL COMPLAINTS (Item 25-31)

These forms record complaints received by the local health department from the public in reference to a wide-range of environmental concerns including air quality, solid waste, hazardous waste, epidemiology, indoor clean air, infectious waste, swimming pools, schools, vector control, food service, landlords, animals, housing, and yards. If complaint pertains to a specific facility it becomes part of the facility's inspection file. The form includes date, time, name of persons taking complaint, complainant's name, address, and telephone number; nature of complaint, date investigated, action taken, completion date, and signature of registered environmental health specialist.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Public.

Suggested Secondary Designation

Private:complainant's name, home address, and telephone number

(Approved 12/92)

 

ENVIRONMENTAL/OCCUPATIONAL INVESTIGATION CASE FILES (Item 25-32)

These are records of epidemiological investigations of environmental and occupational public health hazards. They help prevent those hazards, and assist in short and long-term health studies. As stated in the Utah Code of Communicable Disease Rules, the Department of Health collects this information in order to promote and protect the public health and to prevent and control disease. Includes epidemiological investigations of individuals and/or groups exposed to environmental health hazards, health risk analyses of human exposures to chemical contaminants, cancer cluster investigations, and adverse reproductive outcomes. Medical records may contain patient name, address, sex, race, age, type of exposure, company where possible exposure occurred. The State Bureau of Epidemiology maintains the record copy of these records permanently.

Retention

Retain for 7 years after completion of investigation and then destroy.

Suggested Primary Designation

Public:Health hazard appraisals.

Suggested Secondary Designation

Private:Patient/case files

(Approved 12/92)

 

EXPENDITURES SUMMARY STATEMENT (Item 25-33)

This is a monthly statement sent to the state Department of Health to bill for expenses incurred on state contracts. This statement includes the name of the local health department, month and year, allocation of expenditures by contract type, expenditure category (wages and salaries, fringe benefits, etc.), total amount of expenditures, amount of the collection received, the net amount of expenditures, and date and signature of the certifying official.

Retention

Retain for 3 years or after state health department audit and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

FAMILY PLANNING CLIENT CHARTS (Item 25-34)

These charts document services provided to individuals enrolled in the family planning program funded by federal grants under Section 1001 of the Public Health Service Act. The purpose of the grant is to provide educational, comprehensive medical, and social services necessary to aid families, particularly low income families, to determine freely the number and spacing of their children. These files include a physical examination form, a record of client visits, progress notes, face sheet, financial form, signed consent forms, contraceptive method authorization forms, and laboratory test results.

Retention

Retain for 7 years after the client leaves the program, provided client has reached the age of 21 and then destroy.

Suggested Primary Designation

Exempt:42 CFR 59.15 (2008).

(Approved 12/92)

 

FAMILY PLANNING NEEDS ASSESSMENT REPORTS (Item 25-35)

This is a report submitted to the State Bureau of Family Planning showing the needs for family planning funds and the performance plan for the upcoming year. It is used in distributing grant money. It includes the local district name, the number of births to teens out of wedlock, abortion numbers, the infant mortality rate, the number of births in families below 150 percent of poverty, and the increase or decrease of each category from the previous year. The record copy of this report is retained by the State Bureau of Family Planning permanently.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

FATHER'S PATERNITY ACKNOWLEDGEMENT (Item 25-36)

This state form is used by the father to acknowledge the paternity of a child when he is not married to the child's mother. The original form is retained by the State Health Department permanently. The form includes child's name, birth date and place, mother's name and address, father's name and address, and a notarized signed statement acknowledging child's paternity.

Retention

Permanent. May be transferred to the State Archives.

Suggested Primary Designation

Private.

(Approved 12/92)

 

FETAL DEATH CERTIFICATES (Item 25-99)

These death certificates document all fetal deaths occurring in the State of Utah as required by UCA 26-2-14 (1995). The certificate is required to be filed with the local registrar within five days after the delivery of a dead fetus. The local registrar transmits the certificate to the State Health Department in accordance with UCA 26-2-19 (1995). The certificate includes local and state file numbers, fetus' name and sex, delivery date and time, delivery place, delivery location (city, county), residence (state, county, city, location, address, zip code), race, parent information, pregnancy history, cause of death, attendant's name and signature, disposition of fetus, date, registrar's signature, and medical and health information. The State Health Department retains the official copy permanently while local health departments retain their copies to respond to local requests.

Retention

Permanent.

Suggested Primary Designation

Exempt:UCA 26-2-22 (2008).

(Approved 01/96)

 

FOOD ESTABLISHMENT APPLICATION PERMIT (Item 25-37)

This is an application used to obtain a permit to operate a food establishment. The form includes date, business name, address, and telephone number; applicant's name, address, and telephone number; business type; a statement signed by applicant indicating permit conditions; fee amount; permit number; name of person approving application, and the name and address of property owner.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

FOOD HANDLERS PERMIT APPLICATION RECORDS (Item 25-38)

These forms document the application and issuance of food handlers permits. They include applicant's name, address, and telephone number, date, birth date, sex, physical description, place and address of employment site, whether permit previously issued, and applicant signature.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

FOOD SERVICE ESTABLISHMENT INSPECTION REPORTS (Item 25-39)

These are reports on inspections of food service establishments to ensure that proper methods of food preparation and sanitation are followed. These inspections are authorized under UCA 26-15-15-2(1), 26A-1-113, 26A-1-114(1)(g) (1995). These reports include the name and address of the owner; name of the establishment; inspection purpose (follow-up, regular, etc); the date by which identified violations must be corrected; inspector's comments; and results of the inspection of food, food protection, personnel, food equipment and utensils, water, wastewater, plumbing, toilet and hand washing facilities, solid waste disposal, insect/rodent/animal control, floors, walls, and ceilings, lighting, ventilation, dressing rooms, other operations, living quarters/laundry; the rating score; and inspector's name.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

FOOD SERVICE PLAN REVIEW RECORDS (Item 25-40)

These review forms document the local health department's review of food service plans prior to the opening of the establishment. This is part of the local health departments duties as set out in UCA 26A-1-114(2)(a) (1995). The department reviews floor plans, equipment schedules, plumbing plan and schedule, lighting plan, finish schedule (floors, walls, and ceiling), and equipment details when necessary to determine whether food establishments meet general requirements for bathrooms, washing facilities, plumbing, cooking equipment, grease traps, lighting, waste disposal, and other facilities prior to the opening of the establishment. These forms include the establishment's name, address, mailing address, and telephone number, reviewers name, date, a listing of any areas of concern, and comments.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

GAS LEAK EMISSIONS CHECK REPORT (Item 25-41)

This is a monthly form submitted by inspection stations reporting that their emissions inspection equipment is operating properly. It ensures the accuracy of the data collected by the station. This form includes the name, number, and address of the station; the analyzer's brand name, model and serial number; the gas brand; the propane equivalency factor; the test date; the person performing the gas calibration and leak check; the cylinder pressure; the span gas concentration levels; the calibration port readings; the readjustment readings; the probe readings; the percentage difference; whether the machine passed or failed the check; and a record of any unusual occurrences during the month (analyzer inoperable, maintenance performed, etc.). This form was discontinued July 1, 1991.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

HOTELS, MOTELS, RESORTS, AND LABOR CAMPS INSPECTION REPORT (Item 25-42)

This state report form documents health inspections of all hotels, motels, resorts, and labor camps. Any deficiencies discovered in the inspection must be corrected before next routine inspection or a specified period or facility could be closed until work is completed. The report form includes establishment's name, establishment type, city, county, lodging unit numbers, secondary water source, on-site sewage disposal type, owner's name and address, health district, lessee's name and address, inspection type (routine, complaint, construction inspection, request, follow-up inspection, pre-opening inspection, survey, and other), and results of inspection concerning water supply, wastewater disposal, service buildings or restroom facilities, housing, laundry facilities, swimming or wading facilities, solid waste, and specific remarks, date, and signatures of the owner or representative and sanitarian.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

HUMAN IMMUNODEFICIENCY VIRUS (HIV) CASE FILES (Item 25-43)

These files contain medical and epidemiological information on patients, suspects and contacts for future research and disease intervention strategies. As stated in the Utah Code of Communicable Disease Rules, the reports are intended to enable the Department of Health to protect the public health, and prevent and control communicable disease. Information includes patient's name, telephone number and address; physician's name and telephone number; the hospital; medical record number; name and phone number of the person completing form; date form completed; status report (new case or update); and the reporting health department. The State Bureau of HIV/AIDS Prevention and Control maintains the record copy of positive case files permanently.

Retention

Retain for 4 years after case is closed, providing records for minors are retained until they reach the age of 21 and then destroy.

Suggested Primary Designation

Exempt:UCA 26-6-20.5 (2008), 26-25a-101 (2008).

(Approved 12/92)

 

HUMAN IMMUNODEFICIENCY VIRUS (HIV) CONTROL PROGRAM FILES (Item 25-44)

This is a record of incoming and outgoing correspondence related to the operations of the AIDS Control Program. Includes medical, disease control and patient information regarding AIDS and HIV; narratives; summary data reports; grants information, finance, policies, procedures, rules, regulations, ordinances; and other general program operational files. The State Bureau of HIV/AIDS Prevention and Control maintain the record copy of these records which are transferred to the State Archives after they have been superseded.

Retention

Retain until updated or superseded and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

IMMUNIZATION CARDS (Item 25-45)

These cards document immunizations given by the local health department. They include name, birthdate, sex, address, phone number, type of immunizations, series, date given, and date booster given. Some cards also include the signature of the parent. In 1991, the card was replaced with the immunization record and signature card. The new card records similar information, but also serves as the immunization informed consent card.

Retention

Retain for 10 years after date of last immunization, provided client has reached the age of 21 and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

IMMUNIZATION INFORMED CONSENT CARDS (Item 25-46)

These are forms filled out by parents before their children receive immunization for measles, mumps, rubella, polio, diphtheria, tetanus, and pertussis. Consent is secured to help protect the local department against suit for failure to obtain informed consent under UCA 78-14-5 (1995). These forms include the patient's name, address, age, and date of birth; the signature of the consenting adult; and a printed description of the benefits and risks of the vaccine.

Retention

Retain for 7 years after last visit, provided client has reached the age of 21 and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

IMMUNIZATION PERSONAL EXEMPTION RECORD (Item 25-47)

This is a statewide form provided by the State Health Department to all local health departments. It is used by parents to claim a personal exemption based on a personal belief opposed to immunization in accordance with UCA 53A-11-302.5 (1995). This form must be completed annually to receive continued recognition of the personal exemption. It includes a statement claiming exemption from immunization, parent or guardian's name and signature, address, date, name of child/student exempted, date, school or child care facility's name, witness's signature, title, and date.

Retention

Retain until student reaches age of 21 and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

INDIVIDUAL SEWAGE DISPOSAL SYSTEM RECORDS (Item 25-48)

These files document the approval by the department for the construction of individual sewage treatment equipment, as authorized by UCA 26A-1-115(2) (1995). This form includes the property address, owner or mortgagor name, contractor's name, final inspection date, number of bedrooms, subdivision where property is located, lot number, whether the property has a basement, seepage rate, water supply type and source, water source description, a description of the septic tank (capacity, dimensions, access, etc.), seepage pit description, distribution box description, disposal field description, whether the construction is approved or not, and inspector's name.

Retention

Retain until the system is updated or no longer in use and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

INDIVIDUAL TANNING OPERATOR CERTIFICATE APPLICATION (Item 25-49)

This is an application form completed to obtain certification as a tanning operator. It includes date, applicant's name, address, social security number, telephone number, and description; application date; fees paid; certificate number, indication whether test taken and passed; issue date; and additional information.

Retention

Retain for 3 years after expiration of certificate and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

INDOOR CLEAN AIR ACT COMPLAINTS (Item 25-50)

These forms record complaints received for individuals smoking in public buildings. They include date and time; name, sex, address, birthdate, location of complainant; violator's name and signature; and violator's name.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

INFANT DEVELOPMENT PROGRAM (IDP) CASE FILES (Item 25-51)

These case files document the participation of children in the federal Handicapped Children's Early Education Program under 34 CFR 309 and 315 (1992). This program deals with children from birth to age three. The files include the permission to evaluate form, referral/intake form, health assessment, developmental tests, feeding behaviors assessment form, reflex maturation assessment, home visit report, individual family service plan, medical records, patient release forms, family identification record, IDP roll book, and information sheets, and access to records form.

Retention

Retain until child reaches the age of 21 and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

INSPECTION CERTIFICATE PURCHASE APPLICATION (Item 25-52)

This is an application submitted by an inspection station owner to purchase inspection certificates from the local health department of inspection as required by UCA 41-6-163.6(6) (1995). The application includes the name, station number, and telephone number of the inspection station; names of the owner, manager, and purchaser; purchaser's association with the station; purchaser's address and telephone number; number of compliance certificates requested; a record of the confirmation of the order; amount of money received; and the number of certificates issued.

Retention

Retain for 2 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

INSPECTION/MAINTENANCE AND AUDIT REPORT (Item 25-53)

This report records department inspections of vehicle emission inspection stations to ensure that proper equipment is used and standard procedures followed. This report includes the station's name, permit number, analyzer number, station's address, inspection date, check list, inspection results noting any violations, and inspector's signature.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

INSPECTION/MAINTENANCE CERTIFICATION/RECERTIFICATION EXAMINATION RECORDS (Item 25-54)

These files document the examination of individuals who wish to become certified emissions mechanics. These forms include the name of the mechanic, certification number, business name and address where the mechanic works, date that the emissions course was completed, whether this is a recertification, name of the instructor of the emissions course, final test score, the results of specific test items, and the signature of the auditor.

Retention

Retain for 1 year after the certification is terminated or expired and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

INSPECTION/MAINTENANCE FILES (Item 25-55)

These are the results of the inspection of each vehicle submitted by the inspection stations to the department. This is used to report the test results of the program to report to the Environmental Protection Agency (EPA). These report forms include the vehicle inspection number, engine size and model; owner's name and address; vehicle make; license plate number; model year; test date; station number; mechanic number; inspection cost; test results for tampering, first test emissions level and final test emissions level; certificate number issued; emission repairs costs; and certified emissions mechanic's signature. These forms were discontinued July 1, 1991.

Retention

Retain for 2 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

LABORATORY TEST RESULTS (Item 25-56)

This record is used to assist in the collection of lab test results and to complete patient medical records and verifications of diagnoses. As stated in the Utah Code of Communicable Disease Rules, the Department of Health collects this information in order to protect the public health and protect and control disease. Includes reports such as Request for Serologic Test for Syphilis, Request for Culture of Enteric Bacterial Pathogens, Request for Referred Culture Identification, Report of Antibiotic Sensitivity, Request for Agglutinations and Special Serologic Tests, Request for Miscellaneous Cultures, Request for Rabies Examination, Request for Slide Examination, and Request for Mycobacteria Examination. The State Bureau of Epidemiology retains the record for five years and then destroys.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Exempt:UCA 26-25a-101 (2008).

(Approved 12/92)

 

LICENSED/UNLICENSED DAY CARE FACILITIES, GROUP HOMES, AND JAILS INSPECTION REPORTS (Item 25-57)

These report forms document inspections of licensed/unlicensed day care facilities, group homes, and jails. These inspections are part of the local health departments duties as specified in UCA 26A-1-114 (1)(g) (1995). These forms include facility's name and address, operator's name, facility type, indications whether inspection identified any deficiencies in facility's structure, bathrooms, safety, plumbing, outside facilities, food service, vermin control, housekeeping and general cleanliness, managers signature and telephone number, environmental health specialist's signature and date, and an indication whether inspection approved,conditionally approved, or denied the continued operation of facility. Any identified deficiencies are required to be completed within thirty days or facility could be closed for noncompliance.

Retention

Retain for 6 years or until all ligation settled and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

MEDICAID NOTIFICATION REPORTS (Item 25-58)

This report lists all individuals or families in the county on Medicaid including high risk individuals. It is used to ensure that all individuals eligible to enroll in Medicaid programs are notified and to determine individual eligibility. The report includes case number, recipient name, address, telephone number, and identification number, birth date, whether they have seen a doctor or dentist, date of eligibility, and mother's name.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

Mobile Home Parks, Recreational Parks, and Roadway Rest Stop Inspection Reports (Item 25-29)

These report forms document the health department inspections of mobile home parks, recreational vehicle parks, and roadway rest stops. All deficiencies discovered must be corrected by the next routine inspection or a specified time period or facilities could be closed for noncompliance (UCA 26A-1-114 (1995)). The report form includes name of park or rest stop, city, county, health department, number of spaces occupied (independent, dependent, self-contained), secondary water source, on-site sewage disposal site, owner's/operator's name and address, type of inspection (routine, complaint, construction inspection, request, follow-up, pre-opening, survey, other), inspection results concerning water supply, wastewater disposal, service buildings, swimming and wading facilities, and solid waste disposal, any specific remarks, date, owner's or representative's signature, and sanitarian's signature.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

MONTHLY CEMETERY DEATH REPORT (Item 25-60)

This three-part report form lists all interments and is prepared monthly by all cemeteries in the state and submitted to their local health department as required by UCA 26-2-18(3) (1995). The information is used by the department to verify that all death certificates are being received. The original is retained by the local health department, the first copy is submitted to the State Health Department and the second copy is retained by the cemetery. The form includes the month and year, name and location of the cemetery, death date, deceased's name and age, the county where death occurred, and the name of the funeral home or funeral director.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

MONTHLY FUNERAL DIRECTOR'S DEATH REPORT (Item 25-61)

This three-part monthly report is submitted by funeral directors for each casket furnished and for funerals performed where no casket was furnished as required by UCA 26-2-16(3) (1995). It is used to ensure that all death certificates are filed. The original is maintained by the local health department while the first copy is submitted to the State Health Department and the second copy is retained by the submitting funeral director. The information includes the month of the report, name and location of the funeral home, and a list of deaths for the period giving for each the date of death, name of the deceased, age of the deceased, name of the medical attendant, and the county where death occurred.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

MONTHLY HOSPITAL BIRTH REPORT (Item 25-62)

This three-part form is submitted by hospitals reporting live births that occurred during the month. It is used to ensure that all birth certificates were received as required by UCA 26-2-5 (1995). The original is maintained by the local health department while the first copy is submitted to the State Health Department and the second copy is retained by the reporting hospital. The form includes the month of the report, hospital's name, and a list of births giving the date of birth, the parent's names, the child's sex, and the name of the medical attendant.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

MONTHLY HOSPITAL DEATH REPORTS (Item 25-63)

This three-part form is submitted monthly by all hospitals reporting all deaths, fetal deaths, or abortions that occurred during the month. It is required by UCA 26-2-23(3) (1995) and is used to ensure that all death certificates are filed. The original is maintained by the local health department with the first copy being submitted to the State Health Department and the second copy is retained by the submitting hospital. The form includes the month being reported, hospital's name and location, a list of deaths giving the date of death, the name and age of the deceased, the name of the medical attendant, and the name of the funeral home or funeral director.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

MONTHLY NURSING HOME DEATH REPORT (Item 25-64)

This three-part report form is submitted by nursing homes reporting deaths that occurred during the previous month. This report is required by UCA 26-2-23(3) (1995). It is used to determine whether certificates have been received for all deaths and to create state reports. The original record is kept by the local health department while the first copy is submitted to the State Health Department and the second copy is kept by the nursing home. The information includes the month of the report, the nursing home's name, death date, deceased's name, the age at death, medical attendant's name, and the name of the funeral home or funeral director.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

MONTHLY PROGRAM REPORTS (Item 25-65)

These are monthly reports on various programs administered by the local health department. They are prepared by local health departments on blood pressure, cancer, and cholesterol screenings; child health evaluation care; immigration; immunizations; infant development; prenatal; refugee and tuberculosis programs. They are used for management purposes and to prepare a quarterly report. They include the name of the employee and the local health department, month, the number of initial and follow-up cases, services provided, number of referrals made, and the number of screenings and follow-up letters sent.

Retention

Retain until quarterly report is completed and the information verified and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

MORBIDITY DATA SUMMARY REPORTS (Item 25-66)

These are morbidity statistics for all reportable diseases and diseases of public health importance. As stated in the Utah Code of Communicable Disease Rules, the Department of Health collects this information in order to promote the public health and to prevent and control disease. They are used for federal, state, and local agencies, the general public, and for the functioning and management of the Bureau. Statistics provide information by year, county, month, and show distribution by age and sex. The State Bureau of Epidemiology retains the record copy of these records permanently.

Retention

Retain until administrative need ends and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

OFFICIAL VEHICLE EMISSIONS INSPECTION/MAINTENANCE STATION PERMIT FILES (Item 25-67)

These files document the issuing of permits to inspection stations to conduct emissions inspections on motor vehicles. This activity is required by 42 USCA 7410(2)(G) and UCA 41-6-163.6 (1995). These files include a copy of the permit and the permit application. The application includes the name, address, and business telephone numbers; business owner and the property owner if different; name of the business manager or responsible individual; application approval date; date the permit was issued and permit number; fee amount; and permit's expiration date.

Retention

Retain for 1 year after the permit has expired or has been terminated and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

PRENATAL HEALTH CASE FILES (Item 25-68)

These are case files for women who are eligible for the prenatal (PEPI) program. This program is for low income pregnant women who were presumed eligible for Medicaid or who are on Medicaid. The local health department performs an initial interview to determine the woman's eligibility. Once the woman is determined eligible she is assigned to a registered nurse who then contacts the client every month and performs home visits. Each of these components are documented in each client's chart. The client is maintained in the program for two months after the pregnancy ends. The case file includes prenatal care coordination tracking record form, nursing notes, prenatal initiative form, Utah Perinatal record system (UPRS), identification card, health insurance claim form, and release of information form. These case files may also be called "Baby Your Baby case files."

Retention

Retain for 7 years after last visit and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

PRIVATE WELLS RECORDS (Item 25-69)

These records document the approval of the department for the construction and use of private wells, as authorized by UCA 26A-1-114(1) (1995). The State Health Department maintains the listing of all private wells and retains record copy of state approvals. These records include the property address, owner name, contractor's name, final inspection date, subdivision where property is located, water supply type, source, and description, whether construction approved or not, results of water quality tests, and inspector's name.

Retention

Retain until well is no longer in use and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

PROJECT PRIDE CASE FILES (Item 25-70)

These case files document participation of referred children from kindergarten through the third grade to a special grant program provided to local health departments in conjunction with school districts under the supervision of the State Council for Children and Youth at Risk as provided by UCA 63-75-4 (1995). It is designed to identify children, regardless of family income, at risk as potential school dropouts, and to provide them assistance. The children will be studied until they graduate from high school or turn eighteen. These case files include testing results, demographics, information concerning parents' medical and education history, nurses notes, dental referral forms, vision referral forms, physical and psychological testing forms.

Retention

Retain until child reaches age of 18 or graduates from high school and then destroy.

Suggested Primary Designation

Private.

Suggested Secondary Designation

Controlled:psychological testing records

(Approved 12/92)

 

QUARTERLY DENTAL HEALTH REPORTS (Item 25-71)

These are reports submitted to the State Bureau of Dental Health on district activities in the field of dental health. They are used in preparation of an annual report to be submitted to the Association of State and Territorial Health Officials. The association then publishes a national annual report. These reports include the district name, the report date, the director's name, the number and type of programs for education and prevention held and the number of persons attending, the number of areas fluoridating water, the names of communities fluoridating water and the number of people served, and the number of dentists assisted in placement. The Bureau of Dental Health maintains the record copy of these reports for two years.

Retention

Retain for 1 year and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

QUARTERLY REPORTS (Item 25-72)

These are quarterly reports on various programs administered by the local health departments including blood pressure, cancer, and cholesterol screenings; immigration; child health evaluation care; immunization; infant development; prenatal; refugee; and tuberculosis programs. They are used for management purposes and to provide statistical information about operated programs. These reports include employee's name, local health department name, number of hours worked, job title, date number of clients seen, services provided, and referrals made.

Retention

Retain for 2 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

RECREATIONAL CAMPS AND TEMPORARY MASS GATHERING INSPECTION REPORTS (Item 25-73)

These report forms document the inspection of recreational camps and temporary mass gatherings. The form includes the identification number, facility type, day use area, indication whether camp is modern, semi-developed, semi-primitive and if camp is operated by federal, state, county, city governments, church, youth, private, or other; facility name, camp's maximum capacity, number of dependent/independent/self-contained spaces, number of cabins or shelters used for sleeping purposes; secondary water source and whether it is for outside use; whether camp is on a sampling schedule; whether a water sample was taken at time of inspection; on-site sewage disposal type; whether food service inspection made and inspection report attached; whether a person is trained to render first-aid; owner's or operator's name; local health department's name; whether a permit is needed; for operations; inspection type (e.g., routine, complaint), report of inspection on site, water supply, waste water disposal, service buildings, housing, swimming or wading facilities, solid waste, and first aid facilities; any applicable remarks; date; operator's or representative's signature, and signature of sanitarian. All deficiencies must be corrected before next inspection or specified period or facility could be closed for noncompliance (UCA 26A-1-114(1)(g) (1995)).

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

REFUGEE CLIENT CHART FILES (Item 25-74)

These files document required health assessment of refugees. The original files are retained by the local health Department with some information being sent to the State Health Department. The files include test results, patient questionnaire, chest x-ray report as needed, nurses notes, medication form, and completed physical form.

Retention

Retain for 7 years after case closed and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

SCAVANGER/SALVAGE PERMITS (Item 25-75)

These files document the issuance of permits under the authority of UCA 26A-1-114(1)(a) (1995) allowing the holder to engage in the business of emptying, or cleaning any vault, privy, septic tank, cesspool, or grease trap, automobile salvage, by-product disposal, and recycling. These permits include permit holder's name, the business name, the permit holder's home and business addresses, the date issued, expiration date, the property owner's name, business type, application's approval date and the permit number.

Retention

Retain for 2 years after the permit expires or has been terminated and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

SCHOOL BUILDING INSPECTION RECORDS (Item 25-76)

These files document the inspections conducted by the local health agency to ensure that the school buildings and premises are safe for use by the students and school personnel. This is part of the local health agencies duties as set out in UCA_ 26A-1-114(3) (1995). These inspection forms include school district's name, school type, school's name, enrollment statistics, number of class and work rooms, inspection date, inspector's name, inspector's remarks, and the results of the inspection of the grounds, school rooms, floors, walls, ceilings, chalkboards, heating, ventilation, lighting, seating, water supply, hand washing facilities, toilet facilities, locker facilities, shower rooms, and waste disposal.

Retention

Retain for 6 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

SCHOOL STUDENTS IMMUNIZATION ASSESSMENT ANNUAL REPORT (Item 25-77)

These forms document surveys taken by schools or local health departments of children entering kindergarten and child care to determine immunization status. Copies of the forms are sent to the State Department of Health. The forms include name of facility and responsible party, number enrolled in kindergarten or day care, number of children with immunization cards or records turned in to the school, number of children with no record, number of children adequately immunized, number of exemptions (medical, religious, personal), and total number of exemptions. These records are also called Preschool immunization survey sheets.

Retention

Retain for 2 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

SEXUALLY TRANSMITTED DISEASE CASE FILES (Item 25-78)

These files are used in maintaining and locating medical information, and in the follow up of suspected individuals, cases and contacts with Sexually transmitted diseases (STD) and for controlling the spread of STDs. As stated in the Utah Code of Communicable Disease Rules, the Department of Health is required to maintain this information in order to promote the public health and to prevent and control the spread of disease. The files include laboratory test cards, interstate transmission control identification forms, gonorrhea epidemiologic control records, infectious syphilis epidemiologic control records, original interview information, reinterview record and cluster interview records.

Retention

Retain for 4 years after case is closed, providing records for minors are retained until they reach the age of 21 and then destroy.

Suggested Primary Designation

Exempt:UCA 26-25a-101 (2008).

(Approved 12/92)

 

SEXUALLY TRANSMITTED DISEASE PROGRAM FILES (Item 25-79)

This is a record of incoming and outgoing correspondence related to the Sexually Transmitted Disease (STD) Control Program. Includes financial, medical, disease control and patient information regarding sexually transmitted diseases; policies, procedures, rules, regulations, and ordinances; summary data of STDs by month, quarter and year; and other general program operational files. The State Bureau of Epidemiology maintains the record copy of these records.

Retention

Retain until updated or superseded and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

SUBDIVISION PLATS (Item 25-80)

These are copies of plats prepared by real estate developers showing the layout of lots in a subdivision. The department reviews these plats to ensure that proper sanitary facilities for the lots are included in the plan. The plats include surveyor's name, boundary description, subdivision name, date of acceptance by the legislative body, the date and terms of approval by the local health department, and planning commission's approval date.

Retention

Retain for 1 year or until administrative need ends and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

SUDDEN INFANT DEATH SYNDROME (SIDS) CASE FILES (Item 25-81)

This is part of a federally funded project to research the cause of Sudden Infant Death Syndrome (SIDS). This program is funded under 42 USCA 300c-12 (1991). These records investigate the family background and response to SIDS. The file includes SIDS case information, Nurse Referral Form, and notice from Medical Examiner's Office. Information includes the infant's name and birth date; the date and time found dead; the place of death; the infant's medical history; the maternal and gestation history; record of other SIDS cases in the family; socioeconomic and environmental data; the parents' names, address, dates of birth, religion, educational level, and occupation; the parents' and siblings reactions; the dates of visits; and nurse or counselor's name.

Retention

Retain for 3 years after the case is closed and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

SWIMMING POOL BACTERIOLOGICAL ANALYSES RESULTS (Item 25-82)

These are test results for the inspection of public swimming pools to ensure that they comply with the requirements of UCA 26-15-2(2) (1995). These results include the county name, water supply source, the date the sample was collected, the lab number where tested, the individual name collecting the sample, and the test results.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

SWIMMING POOL INSPECTION REPORT (Item 25-83)

This is a report on the inspection of public swimming pools as required by UCA 26A-1-114(1) and 26-15-2 (1995). This report form includes the pool name, pool address, owner's name, operator's name, the date and time of the inspection, the number of bathers during the inspection, inspector's name, and inspection results.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

SWIMMING POOL PERMITS (Item 25-84)

These files document the issuance of permits by the health department to operate public swimming pools. The permits include the permit holder's name, the business name, the permit holder's home and business addresses, date issued, expiration date, property owner's name, type of business, date application approved, and permit number.

Retention

Retain for 2 years after the permit expires or has been terminated and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

TANNING ESTABLISHMENT INSPECTION RECORDS (Item 25-85)

These forms document inspections of tanning facilities. They include owner's name, establishment's name and address, any comments, indications on facilities physical features, operation, cleaning and maintenance, certifications, advertising, any additional requirements, and inspector's signature.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

TANNING ESTABLISHMENT PERMIT APPLICATION (Item 25-86)

This is an application form used to obtain a permit to operate a tanning establishment. The form includes date, business name, address, and telephone number; applicant's name, address, and telephone number; business type; a statement signed by applicant indicating permit conditions; fee amount; permit number; name of person approving application, and name and address of property owner.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

TUBERCULOSIS CLIENT CHART FILES (Item 25-87)

These case files document services provided to clients being treated for active diseases or for a positive tuberculin test reaction. The original files are retained at local health department, with certain information being sent to the State Health Department. The files include a questionnaire, test results, chest x-rays report as needed, information consent forms, medication sheet, and nursing notes.

Retention

Retain for 7 years after case closed and then destroy, provided patient has reached the age of 21.

Suggested Primary Designation

Private.

(Approved 12/92)

 

UNDERGROUND CLOSURE/INSTALLATION PERMIT APPLICATION (Item 25-88)

This is an application form used to obtain a permit to either close or install an underground storage tank. The form includes the date, owner's name, address, and telephone number; contractor's name, address, and telephone number; location of underground storage tank, name/business and address; indication whether application is for the installation or closure of underground storage tank(s) listing number of tanks, whether fee has been paid, and if for closure whether a state approved closure plan was noted or if for installation whether installation plans approved prior to permit issuance; amount of fee paid; permit number; approval signature, applicant's name and signature; and closure/installation date.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

VAPOR RECOVERY VIOLATION NOTICES (Item 25-89)

These notices are given to tanker truck drivers who have vented gas vapors while discharging gas. Environmental laws require tanker trucks' hoses to force vapors back into the truck while discharging gasoline. The notices include date and time of violation; name, sex, address, and birthdate of violator; location of violation; explanation of of violation; and officer's signature.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

VEHICLES OPERATING EXCLUSIVELY OUT-OF-STATE OWNERSHIP AFFIDAVITS (Item 25-90)

These affidavits are prepared by owners of motor vehicles that indicate they will not be operating their vehicles in the state of Utah. As the purpose of emissions testing is to improve the air quality in Utah, a citizen taking a vehicle out of the state is not required to pay for the emission tests. This form provides this citizen exemption, yet enables local health agencies to follow-up to ensure that the vehicle is tested when it is returned to the state. This affidavit includes the owner's name, telephone number, and address; the vehicle make; the license number; vehicle's serial number; model year; and the anticipated date of return.

Retention

Retain until certificate of compliance is received from the vehicle owner or 18 months, whichever comes first and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

VITAL STATISTICS AMENDMENT AFFIDAVIT (Item 25-91)

This is a state form used to amend a birth, death, or fetal death certificate. This completed form is sent to the State Health Department and after its final approval it becomes part of the original state record and a copy is returned to the local health department. The form includes local certificate number, indication whether birth, death, or fetal death certificate, state certificate number, name, sex, event date and place, names of father and mother, facts on original records and facts as they should have been stated at time of occurrence, and notarized signatures of two witnesses.

Retention

Permanent. May be transferred to the State Archives.

Suggested Primary Designation

Exempt:UCA 26-2-22 (2008).

(Approved 12/92)

 

WASTE TIRE PERMIT APPLICATION (Item 25-92)

This is an application used to obtain a permit to operate a waste tire business. The form includes date, business name, address, and telephone number; applicant's name, address, and telephone number; business type; a statement signed by applicant indicating permit conditions; fee amount; permit number; name of person approving application, and name and address of property owner.

Retention

Retain for 3 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

WATER BACTERIOLOGICAL ANALYSES RESULTS (Item 25-93)

These are the results of tests of water sources such as wells to ensure that the water meets all health standards. These tests are authorized by UCA 26A-1-114(2)(d)_(1995). These test results include county name, water supply source, the date sample was collected, lab number where tested, individual's name collecting the sample, and the test results.

Retention

Retain for 4 years and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

WOMEN, INFANTS, AND CHILDREN (WIC) CHILDREN'S PARTICIPANT FILES (Item 25-96)

These files document the participation of children in the Women, Infants, and Children (WIC) Program. The purpose of the program is to provide supplemental foods and nutrition education to low income families in accordance with the provisions of 7 CFR 246_(1993). This program is open to children between the ages of one and five. These files include the nutritional education record, lost or stolen WIC Voucher/ID Card Report, WIC certification form, nutrition care plan, nutrition education information, WIC participant responsibilities agreement, turnaround change order, family enrollment form, growth charts, infant/child medical history, nutrition history, and correspondence.

Retention

Retain until child reaches the age of 10 years (Utah Administrative Code, R406-100-7 (1995) and then destroy.

Suggested Primary Designation

Private.

(Approved 12/92)

 

WOMEN, INFANTS, AND CHILDREN (WIC) PROGRAM FINANCIAL RECORDS (Item 25-94)

These records document the expenditure of monies for projects funded under the WIC program. These records include receipts, check registers, and a variety of financial reports.

Retention

Retain for 3 years after submission of annual or final expenditure report (7 CFR 246.25(a)(2) (1993)) and then destroy.

Suggested Primary Designation

Public.

Suggested Secondary Designation

Private:names, address, telephone numbers, and expenditures to individual client's

(Approved 12/92)

 

WOMEN, INFANTS, AND CHILDREN (WIC) PROGRAM OPERATIONAL RECORDS (Item 25-95)

These records document the operations of local WIC programs. These records include a variety of preliminary reports (monthly, activity, summary reports) and related correspondence.

Retention

Retain for 3 years after submission of annual or final expenditure report (7 CFR 246.25(a)(2) (1993)) and then destroy.

Suggested Primary Designation

Public.

(Approved 12/92)

 

WORK EDUCATION AND TRAINING PROGRAM (WEAT) CASE FILES (Item 25-98)

These case files document participation in the Work Education and Training (WEAT) program. This program is for women on welfare. It is designed to help participants become self-sufficient through the work experience and training they receive at their work site. Participants receive between six to twelve months training and work experience in the public sector and are paid minimum wage. The case files include an interview sheet, time sheet, and participant evaluation forms.

Retention

Retain for 1 year after client leaves program and then destroy.

Suggested Primary Designation

Private.

Suggested Secondary Designation

Public:UCA 63G-2-301(1)(b) (2008)

(Approved 12/92)