PRIVACY NOTICE (NON-PUBLIC RECORDS)

Why We Collect Your Data and How We Use It

We collect your personal, financial, and medical information (including your name, contact information, Social Security number, citizenship status, household income, pregnancy status, and household size) to evaluate your preliminary eligibility for temporary Medicaid coverage under the Baby Your Baby (BYB) / Prenatal (PEPI) program. We use this information to process your application, provide prenatal care coordination, conduct nursing visits, and forward your application to the Department of Workforce Services (DWS) to determine your eligibility for continued medical benefits. Social Security numbers and citizenship statuses are strictly collected because they are legally mandated by state and federal law to verify identity and Medicaid eligibility.

Consequences of Refusing to Provide Information

Providing this personal data is required to determine your eligibility for benefits. If you choose not to provide the requested information, we will be unable to assess your application, which may result in you being denied temporary Medicaid coverage and associated prenatal care coordination services.

Record Series and Privacy Classification

The personal data you furnish will be filed under our official Record Series for Patient and Client Case Files (State Schedule GRS-1706). Under the Government Records Access and Management Act (GRAMA), the information collected on this application is classified as a Private or Controlled record. Private records are legally available to the subject of the record, the parent or legal guardian of a minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. Because this form collects sensitive medical history and pregnancy status, portions of this record may be classified as Controlled. Controlled records are restricted from the subject and are only released to qualified medical or health professionals upon submission of a release, specifically if releasing the medical information directly to the subject would be detrimental to their mental health or safety, or violate medical ethics. It will be retained for 7 years after your case is closed, or for 22 years after the date of birth (whichever is greater), before being securely destroyed.

Who We Share Your Data With

To fulfill your request and comply with legal requirements, the personal data you provide on this application is shared directly with the Department of Workforce Services (DWS), the Utah Department of Health and Human Services (DHHS), and authorized Tribal organizations as required to coordinate care and benefits. We do not use commercial third-party contractors to process this data; we do not sell your personal data to any third parties, and it is not shared with any commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on this application by contacting the SWUPHD Records Officer. Please note: Requests to amend or correct this data will only apply to the local prenatal case files held by the Southwest Utah Public Health Department and cannot be used to legally amend official Medicaid enrollment or financial records held by the Department of Workforce Services (DWS).

Why We Collect Your Data and How We Use It

We collect your personal identifying information, demographics, insurance details, and sensitive medical history (including prior illnesses, allergies, and pregnancy status) to assess your health risks, safely administer vaccines and prophylactic medications, provide accurate health and travel consultations, process medical billing, and legally secure written consent for treatment. For supplemental forms, this information is used to legally authorize the release of your medical records or to process your requests to amend your health information.

Consequences of Refusing to Provide Information

Providing this personal data is voluntary; however, if you choose not to provide the requested information, our clinical staff will be unable to safely assess your health risks, determine vaccine contraindications, administer requested vaccines or medications, process your insurance billing, or fulfill your medical record release and amendment requests.

Record Series and Privacy Classification

The personal data you furnish will be filed under our official Record Series 16686: Immunization records – Tracking cards. Under the Government Records Access and Management Act (GRAMA), the information collected on these forms is classified as a Private or Controlled record. Private records are legally available to the subject of the record, the parent or legal guardian of a minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. Because this form collects sensitive medical history, portions of this record may be classified as Controlled. Controlled records are restricted from the subject and are only released to qualified medical or health professionals upon submission of a release, specifically if releasing the medical information directly to the subject would be detrimental to their mental health or safety, or violate medical ethics. It will be retained for 10 years after your last visit or until the client has reached the age of 21 before being securely destroyed.

Who We Share Your Data With

To provide your care and fulfill public health operations, the personal data you provide is shared directly with the Utah Statewide Immunization Information System (USIIS), your health insurance provider, and consulting medical professionals (such as the University of Utah for travel medicine). We also share your personal data with Connexin Software, Inc., which maintains our Electronic Health Record (EHR) system (Office Practicum), and with our merchant gateway provider solely for the purpose of processing financial payments. These commercial third-party vendors are contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing these specified services to the Department. We do not sell your personal data to any third parties, and it is not shared with any other commercial or governmental entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on these forms by contacting the Southwest Utah Public Health’s Clinical Services division. Please note: Requests to amend or correct this data will only apply to the local medical and billing files held by the Southwest Utah Public Health Department and cannot be used to legally amend official state records held within the Utah Statewide Immunization Information System (USIIS) or your private health insurance records.

Why We Collect Your Data and How We Use It

We collect your personal identifying information and your child’s medical data (including parent/guardian name, child’s name, date of birth, and specified exemption reasons—personal, medical, or religious) to legally document your child’s exemption from required immunizations. We only use this information to verify the completion of the state-mandated online vaccination education module and to fulfill official public health and educational enrollment requirements under Utah law.

Consequences of Refusing to Provide Information

Providing this personal data is required to obtain a valid vaccination exemption. If you choose not to provide the requested information, we will be unable to legally issue the exemption certificate, which may result in your child being denied enrollment or attendance at a school or child care facility unless they receive the state-mandated vaccines.

Record Series and Privacy Classification

The personal data you furnish will be filed under our official Record Series 16846: Immunization personal exemption record. Under the Government Records Access and Management Act (GRAMA), the information collected on this form is classified as a Private record. Private records are legally available to the subject of the record, the parent or legal guardian of a minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. It will be retained for 21 years after the child’s date of birth before being securely destroyed.

Who We Share Your Data With

To fulfill your request and comply with legal requirements, we share your personal data with Connexin Software, Inc., which maintains our Electronic Health Record (EHR) system (Office Practicum), who are contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing these specified services to the Department. We do not share this data with the Utah Statewide Immunization Information System (USIIS), the Utah Department of Health and Human Services (State Health Department), or the specific school or child care facility where your child is enrolled. We do not use any other commercial third-party contractors to process this data; we do not sell your personal data to any third parties, and it is not shared with any other commercial or governmental entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on this form by contacting the Southwest Utah Public Health Department’s Clinical Services division. Please note: Requests to amend or correct this data will only apply to the local exemption records held by the Southwest Utah Public Health Department and cannot be used to legally amend records you have already physically submitted to a school or child care facility.

Why We Collect Your Data and How We Use It

We collect the decedent’s identifying information (including full name, sex, age, birth date, birthplace, and date/county of death)—though the name is not strictly required for fetal remains under 20 weeks gestational age. We also collect the name, relationship, and mailing address of the authorizing person or facility, alongside the funeral director or dispositioner’s details and the intended method and location of final disposition (such as a specific cemetery or crematory). Additionally, we collect payment details for your transaction, and, as mandated by the Utah Vital Records office, we are required to collect and retain a copy of any out-of-state identification, passports, visas, or other government-issued identification. We use this information exclusively to legally authorize and document the transportation, out-of-state transit, cremation, or final disposition of human or fetal remains. We also use this data to ensure compliance with state law by verifying that satisfactory proof of a death certificate or fetal death certificate has been filed before the permit is issued. Please note that payment details are collected solely for immediate processing and are not retained by the Vital Records Department.

Consequences of Refusing to Provide Information

Providing this data is legally required to authorize the movement and final disposition of human or fetal remains, particularly when remains are being transported out of Utah or when disposition is made by someone other than a licensed funeral director. If you choose not to provide the requested information, the local or state registrar cannot issue the Burial Transit Permit. Without this legal permit, a sexton or cemetery manager cannot allow the interment of the remains, and the body or fetus cannot be legally transported out of state, cremated, or otherwise reach final disposition.

Record Series and Privacy Classification

The data you furnish on the application will be filed under our official vital Records Series: 13679 Death Hold Book, mapped to the state’s General Retention Schedule GRS-285: Vital records. Under the Government Records Access and Management Act (GRAMA), permits acting as official legal documentation of the final disposition of remains may be classified as Public records. Any underlying personal data is classified as a Private record (available to the surviving spouse, next of kin, the legally appointed personal representative of the estate, or as otherwise designated by Utah Code), while underlying medical, psychiatric, or psychological data is classified as a Controlled record (subject to strict access restrictions and generally only available to medical professionals or public health agencies). As instructed by the Utah Vital Records office, these applications and identification copies are kept for 1 year after the end of the calendar year and then destroyed. Payment receipts are transferred to our accounting department and filed under GRS-106 (Local government accounts payable and receivable records), where they are retained for 4 years to fulfill government financial obligations.

Who We Share Your Data With

To fulfill legal requirements for the movement and disposition of human remains, the data provided on this permit is shared directly with the Utah Department of Health and Human Services (State Office of Vital Records and Statistics), local health department registrars, the funeral director or authorized dispositioner handling the remains, and the sextons or managers of the receiving cemeteries or crematories. To process your request, the information you provide is verified against the State of Utah’s Integrated Registration Information System (IRIS) to generate the physical permit document you receive upon completion; your application data is not entered into the IRIS database by our department. We do not sell your personal data to any third parties. Additionally, we share personal data with third-party payment processing companies that handle your transaction, who are contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing these specified services to the Department.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you may request an amendment or correction to the personal data you have submitted on this application by contacting the Southwest Utah Public Health Department’s Vital Records division. Please note: Personal data collected with this paperwork is only used to process this request. Requests to amend or correct this data will only be used to correct application data held by the Southwest Utah Public Health Department and cannot be used to amend a certificate, permit, or other official vital record.

Why We Collect Your Data and How We Use It

We collect your personal identifying information (including your name, contact information, and photocopies of acceptable identification), the specific vital record details needed to locate a death record, and payment details. We use this information exclusively to verify your identity, establish your legal relationship to the certificate holder, process associated fees, and fulfill your request for a certified copy or issue a Certificate of Search if the record cannot be located or you are not legally entitled to it. Please note that payment details are collected solely for immediate processing and are not retained in your vital records application file. As mandated by the Utah State Office of Vital Records and Statistics, we are required to collect and retain a copy of out-of-state identification, passports, visas, or other government-issued identification.

Consequences of Refusing to Provide Information

Providing this personal data and proof of identity is legally required to access non-public vital records. If you choose not to provide the requested information, missing application details, or acceptable identification, we will be unable to verify your identity or legal entitlement, which will result in your application being denied and returned.

Record Series and Privacy Classification

The personal data you furnish on the application will be filed under our official Record Series 13678: Death certificate applications. Under the Government Records Access and Management Act (GRAMA), the information collected on these forms is classified as a Private record and is available to the surviving spouse, next of kin, the legally appointed personal representative of the estate, or as otherwise designated by Utah Code. If supplementary documentation provided to prove your legal relationship contains medical or psychological data, that specific data will be classified as a Controlled record under GRAMA. Unlike Private records, access to Controlled medical data is strictly limited to authorized licensed healthcare professionals or as otherwise explicitly defined by Utah Code § 63G-2-202. It will be retained for 1 year after the end of the calendar year in which the administrative need ends before being securely destroyed. Payment receipts are transferred to our accounting department and filed under GRS-106 (Local government accounts payable and receivable records), where they are retained for 4 years to fulfill government financial obligations.

Who We Share Your Data With

To fulfill your request and comply with legal requirements, the personal data you provide on these forms is shared directly with the Utah Department of Health and Human Services (State Office of Vital Records and Statistics) to verify the record and issue the certificate. We do not sell your personal data to any third parties. Additionally, we share personal data with the following classes of entities to facilitate our official processing duties: third-party payment processing companies that handle your transaction, and contracted IT vendors hosting our application databases, who are contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing these specified services to the Department.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you may request an amendment or correction to the personal contact or payment data you have submitted on this application by contacting the Southwest Utah Public Health Department Vital Records Division. Please note: This procedure applies only to the application data held by the Southwest Utah Public Health Department. It cannot be used to amend or correct the official death certificate itself. To request an amendment to an official vital record, you must follow the legal amendment procedures established by the Utah State Office of Vital Records and Statistics.

Why We Collect Your Data and How We Use It

We collect the decedent’s identifying information (name, sex, date of birth, place of death) and current and future cemetery locations, along with the personal identifying information, relationships, and signatures of the next of kin, new grave owner, and funeral director or authorized agent. We also collect payment details for your transaction. We use this information exclusively to legally authorize and document the disinterment, cremation, reinterment, out-of-state transit, or autopsy of human remains, and to verify that a majority of the next of kin have formally consented to the action. Please note that payment details are collected solely for immediate processing and are not retained in the permanent permit file.

Consequences of Refusing to Provide Information

Providing this data and the required signatures is legally required to authorize the movement of human remains. If you choose not to provide the requested information or fail to secure the signatures of a majority of the next of kin, the local or state registrar cannot issue the permit. As a result, the remains cannot be legally disinterred, relocated, or otherwise altered.

Record Series and Privacy Classification

The data you furnish on the application will be filed under our official Record Series 13682: Disinterment permit. Under the Government Records Access and Management Act (GRAMA), the final authorized permit documenting the movement of remains is classified as a Public record. However, to protect your privacy, the underlying personal contact information and signatures of the next of kin are classified as a Private record and are available only to the individuals who submitted the data, their legally authorized representatives, or as otherwise designated by Utah Code. Because these permits act as official legal documentation of the final disposition and movement of remains, they are legally required to be retained permanently and may be transferred to the State Archives. We maintain the official record copy of this permit before the physical document is given to the client. Payment receipts are transferred to our accounting department and filed under GRS-106 (Local government accounts payable and receivable records), where they are retained for 4 years to fulfill government financial obligations.

Who We Share Your Data With

To fulfill legal requirements for the movement of human remains, the data provided on this application is shared directly with the Utah Department of Health and Human Services (State Office of Vital Records and Statistics), local health department registrars, the funeral director or authorized agent handling the disposition, and the sextons or managers of the present and future cemeteries. To process your request, the information you provide may be verified against the State of Utah’s Integrated Registration Information System (IRIS) to generate the physical permit; your application data is not entered into the IRIS database by our department. We do not sell your personal data to any third parties. We share personal data with third-party payment processing companies to handle your transaction, who are contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing these specified services to the Department. We do not use commercial IT vendors to host this data, and it is not shared with any other commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you may request an amendment or correction to the personal contact or payment data you have submitted on this application by contacting the Southwest Utah Public Health Department’s Vital Records division. Please note: Personal data collected with this paperwork is only used to process this request. Requests to amend or correct this data will only be used to correct data held by the Southwest Utah Public Health Department and cannot be used to legally amend a certificate, permit, or other official vital record.

Why We Collect Your Data and How We Use It

We collect the decedent’s comprehensive demographic, familial, and medical data (including their Social Security number, education level, occupation, parents’ names, and place/cause of death) as well as your personal identifying and contact information as the dispositioner or informant. We use this information exclusively to legally register the death, create the official permanent death record and certificate, follow up with you if additional information is needed, and legally authorize the final disposition (burial, cremation, or transit) of the remains. The decedent’s Social Security number is strictly collected because it is mandated by state and federal law for vital statistics and Social Security Administration reporting.

Consequences of Refusing to Provide Information

Providing this data is legally required to register a death in the State of Utah. All fields on the worksheet are required unless explicitly marked as optional; if you choose not to provide the requested information, we will be unable to legally register the death record. This failure will result in a delay of the official death record and may prevent or delay the final disposition or burial of the remains. (Note: Intentionally providing false information on this form to fraudulently register a death is a Class B misdemeanor and can result in civil penalties of up to $5,000 and imprisonment.)

Record Series and Privacy Classification

The demographic and personal data you furnish will initially be filed under the state-assigned Record Series 81448: Decedent Demographic Data. Because this information legally becomes part of the official death certificate, it is tied to our permanent vital records (such as Record Series 13676 or 29748: Death certificates), which are legally required to be retained permanently for 50 years. Under the Government Records Access and Management Act (GRAMA) and Utah Code 26B-8-125, the decedent’s medical data and cause of death are classified as Controlled records. The dispositioner’s personal contact information and the decedent’s demographic data are classified as Private records. It is restricted from the general public and only accessible to individuals with a direct, tangible, and legitimate legal interest.

Who We Share Your Data With

To fulfill legal death registration requirements, the data provided on this form is shared directly with the funeral home handling the disposition, the certifying physician, the Office of the Medical Examiner (if applicable), and the Utah Department of Health and Human Services (State Office of Vital Records and Statistics). To process this registration, the information is entered directly into the State of Utah’s official electronic vital records systems (such as EDEN/IRIS), which are maintained by the State and its approved technical contractors. We do not sell your personal data to any third parties. We share personal data with the funeral home handling the disposition to facilitate our official processing duties. Any technical contractors interacting with this data are contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing specified services to the State or Department. We do not share your data with any other commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you may request an amendment or correction to the personal contact data you have submitted on this application by contacting the Southwest Utah Public Health’s Vital Records division. Please note: Requests to amend or correct this data will only be used to correct application data held by the Southwest Utah Public Health Department and cannot be used to legally amend an official death certificate or vital record.

Why We Collect Your Data and How We Use It

We collect the spouses’ identifying information (names and the place and date of the marriage or divorce) as well as your personal identifying information (including your name, contact information, relationship to the certificate holders, and photocopies of acceptable identification) and payment details. We use this information exclusively to verify your identity, establish your legal entitlement and relationship to access a restricted vital record, process associated fees, and fulfill your request for a certified copy of a marriage or divorce certificate. Please note that payment details are collected solely for immediate processing and are not retained with the application.

Consequences of Refusing to Provide Information

Providing this personal data and proof of identity is legally required to access non-public vital records. If you choose not to provide the requested information, acceptable identification, or proof of relationship/legal need, we will be unable to verify your identity or legal entitlement. This will result in your application being denied and returned to you. If required information is missing from the application, you will have 90 days to provide it before you must repay the fees.

Record Series and Privacy Classification

The personal data you furnish on the application will be filed under Record Series 13675 to accommodate the Utah Office of Vital Records mandate to destroy the application after 1 year. Under the Government Records Access and Management Act (GRAMA), the information collected on these applications is classified as a Private record. Private records are restricted from the general public and are legally available only to the subject of the record, the parent or guardian of a minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. Payment receipts are transferred to our accounting department and filed under GRS-106 (Local government accounts payable and receivable records), where they are retained for 4 years to fulfill government financial obligations.

Who We Share Your Data With

To fulfill your request and comply with legal requirements, the personal data you provide on these forms is shared directly with the Utah Department of Health and Human Services (Office of Vital Records and Statistics) to verify the record and issue the certificate. To process your request, the information you provide is verified against the State of Utah’s electronic vital records database; your application data is not entered into the state database by our department. We do not sell your personal data to any third parties. We share personal data with third-party payment processing companies to handle your transaction, who are contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing these specified services to the Department. We do not share your data with any other commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you may request an amendment or correction to the personal contact or payment data you have submitted on this application by contacting the Southwest Utah Public Health Department’s Vital Records division. Please note: Personal data collected with this paperwork is only used to process this request. Requests to amend or correct this data will only be used to correct application data held by the Southwest Utah Public Health Department and cannot be used to legally amend a marriage, divorce, or other official vital record.

Why We Collect Your Data and How We Use It

We collect your personal identifying information (including your name, contact information, and photocopies of acceptable identification), the specific vital record details needed to locate a stillbirth or fetal death record, and payment details. We use this information exclusively to verify your identity, establish your legal relationship to the subject of the certificate, process associated fees, and fulfill your request for a certified copy or issue a Certificate of Search if the record cannot be located or you are not legally entitled to it. Please note that payment details are collected solely for immediate processing and are not retained in your vital records application file. As mandated by the Utah State Office of Vital Records and Statistics, we are required to collect and retain a copy of out-of-state identification, passports, visas, or other government-issued identification.

Consequences of Refusing to Provide Information

Providing this personal data and proof of identity is legally required to access non-public vital records. If you choose not to provide the requested information, missing application details, or acceptable identification, we will be unable to verify your identity or legal entitlement, which will result in your application being denied and returned.

Record Series and Privacy Classification

The personal data you furnish will be filed under the state’s General Retention Schedule GRS-1720: Transitory tracking records. Under the Government Records Access and Management Act (GRAMA), the information collected on these forms is classified as a Private record and is available to the parents listed on the record, the surviving spouse, next of kin, the legally appointed personal representative of the estate, or as otherwise designated by Utah Code. If supplementary documentation provided to prove your legal relationship contains medical or psychological data, that specific data will be classified as a Controlled record under GRAMA. Unlike Private records, access to Controlled medical data is strictly limited to authorized licensed healthcare professionals or as otherwise explicitly defined by Utah Code § 63G-2-202. It will be retained for 1 year after the end of the calendar year in which the administrative need ends before being securely destroyed. Payment receipts are transferred to our accounting department and filed under GRS-106 (Local government accounts payable and receivable records), where they are retained for 4 years to fulfill government financial obligations.

Who We Share Your Data With

To fulfill your request and comply with legal requirements, the personal data you provide on these forms is shared directly with the Utah Department of Health and Human Services (State Office of Vital Records and Statistics) to verify the record and issue the certificate. We do not sell your personal data to any third parties. Additionally, we share personal data with the following classes of entities to facilitate our official processing duties: third-party payment processing companies that handle your transaction, and contracted IT vendors hosting our application databases, who are contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing these specified services to the Department.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you may request an amendment or correction to the personal contact or payment data you have submitted on this application by contacting the Southwest Utah Public Health Department Vital Records Division. Please note: This procedure applies only to the application data held by the Southwest Utah Public Health Department. It cannot be used to amend or correct the official stillbirth certificate itself. To request an amendment to an official vital record, you must follow the legal amendment procedures established by the Utah State Office of Vital Records and Statistics.

Why We Collect Your Data and How We Use It

We collect your identifying and contact information—specifically your first name, last name, email address, phone number, and county—along with the category and description of your request. We use this information to accurately route your inquiry to the appropriate Southwest Utah Public Health Department (SWUPHD) personnel and to respond to your questions, comments, or requests for services.

Consequences of Refusing to Provide Information

Providing this information is entirely voluntary. However, if you choose not to provide the requested contact data or description, we will be unable to process your inquiry, route it to the correct department, or contact you with a response.

Record Series and Privacy Classification

The data you furnish will be filed under Customer Request or Complaint Records (GRS-1783). Under the Government Records Access and Management Act (GRAMA), the personal data collected in this form is classified as a Private record and will not be disclosed to the general public or commercial entities. Your request data will be retained for 3 years, and then securely destroyed in accordance with state retention schedules.

Who We Share Your Data With

We do not sell your personal data to any third parties. To process your inquiry, the information provided on this form is used internally by SWUPHD staff and relevant departments. Because this request is submitted digitally, your data may be processed and stored through authorized third-party IT hosting infrastructure providers and state health communication platforms.

Procedure to Correct Personal Data

You may request access to or correction of your personal data by contacting our Records Officer at (435) 673-3528. Additionally, you have the right to file a data privacy complaint with the state data privacy ombudsperson. If you are an “at-risk government employee” (such as a peace officer or judge), you may request that your personal information be classified as a private record by submitting a written application to our agency.

Website Disclosures

This website is operated by the Southwest Utah Public Health Department. This website does not use tracking cookies. We do collect standard IP addresses strictly for web traffic monitoring and site security. This background server data is not connected to your personal request form and is managed separately as a Transitory Tracking Record (GRS-1720).

Part 1: Public Record Statement (Media)

Because the photographs, videos, or audio media captured of you would be classified as a public record under Section 63G-2-301, this privacy notice is legally limited to the following statement: Your personal data may be available to the public as provided by Section 63G-2-201.

Part 2: Private Record Statement (Release Form)

Your signed release form is classified as a Private record under GRAMA (Section 63G-2-302) and is subject to the following data practices:Reasons for Collection and Intended Uses: We collect your identifying information (printed name, signature, and date) to document your authorization for the Southwest Utah Public Health Department (SWUPHD) to capture and use your media. The signed release form is used strictly to verify your consent.

Consequences of Refusing to Provide Personal Data: Providing this consent is entirely voluntary. If you refuse to sign the release or provide the requested information, it will result in the inability of SWUPHD to photograph, video, or interview you or your family, and your image or voice will not be included in our public-facing materials.

Classes of Persons and Entities that Share or Receive Your Data: Your personal data is not sold. The Private release form is only shared internally with SWUPHD administrative staff, our legal counsel, and state compliance auditors.

Record Series: Your signed release form will be securely maintained as part of our Public Relations Records (GRS-1716).

Why We Collect Your Data and How We Use It

We collect your identifying and contact information—specifically your first name, last name, and email address—along with any optional comments you choose to provide. We use this information to process your subscription request and to periodically email you the “Healthy Living – Happy Life” newsletter and other public health updates from SWUPHD.

Consequences of Refusing to Provide Information

Providing this information is entirely voluntary. If you choose not to provide the requested data, we will be unable to process your subscription request, which will result in your inability to receive the newsletter.

Record Series and Privacy Classification

To protect your inbox, the data collected on this form is classified as a Private record under the Government Records Access and Management Act (GRAMA) and will not be disclosed to the general public or third-party marketers. Your subscription data will be filed under Public Relations Records (GRS-1716). It will be retained for as long as you remain subscribed or until the administrative need ends, and then securely destroyed in accordance with state retention schedules.

Who We Share Your Data With

We do not sell your personal data. To process your subscription and deliver the newsletter, the information provided on this form is used internally by SWUPHD’s Communications Team. We share your personal data with our authorized third-party email and cloud service providers strictly for the purpose of processing and storing the subscription list.

Procedure to Correct Personal Data

You may seek access to your personal data, request to correct or amend your data, or file a complaint with the data privacy ombudsperson by contacting our office. Furthermore, if you are an “at-risk government employee,” you may request that your personal information be classified as a private record under Utah Code § 63G-2-302 by submitting a written application.

Why We Collect Your Data and How We Use It

We collect identifying and contact information from you as a parent or caregiver, along with information assessing your household needs and specific child safety requirements (such as your child’s age, weight, and height). We use this information to accurately determine your eligibility to receive a free car seat through our program.

Consequences of Refusing to Provide Information

Providing this information is required to apply for the program. If you choose not to provide the requested data, we will be unable to assess your household need or child safety requirements, which will result in our inability to determine your eligibility and provide you with a free car seat.

Record Series and Privacy Classification

The data you furnish will be filed under our official records (such as Record Series 14311: Car seat rental agreement). Under the Government Records Access and Management Act (GRAMA), these program records are classified as Private records. Private records are legally available to the subject of the record, the parent or legal guardian of an unemancipated minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. Your application data will be retained for 4 years after the expiration of the agreement or application process, and then destroyed in accordance with state retention schedules.

Who We Share Your Data With

Because this record is classified as a Private record under GRAMA to protect your financial and household information, your personal data will NOT be shared with or made available to the general public. To process your application, the information provided on this form is used internally by the Southwest Utah Public Health Department. We rely solely on the information you provide on this application; no external agencies, databases, or persons share personal data with us to cross-reference or verify your claims. Additionally, our authorized third-party cloud service provider (Google Forms) receives your personal data from us on a regular or contractual basis to digitally process and store the application. Google LLC is contractually prohibited from retaining, using, or disclosing this data for any purpose other than providing these specified services to the Department. We do not sell your personal data to any third parties, and we do not share your personal data with any other commercial entities outside of these designated receiving classes.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on this form by contacting the Southwest Utah Public Health Department’s Community Health division. Please note: Requests to amend or correct this data will only apply to the local application files held by our department.

Why We Collect Your Data and How We Use It

The Southwest Utah Public Health Department collects supplemental personal data during your WIC clinic visits—such as nutrition care plans, growth charts, infant/child medical history, pregnancy history, attendance records, lost/stolen voucher reports, and WIC participant responsibilities agreements. This information is used locally by WIC clinic staff to determine your ongoing eligibility, develop customized nutrition and health care plans for you and your child, and manage the administrative operations of the supplemental food program.

Consequences of Refusing to Provide Information

Providing this supplemental health information and signing the required participant responsibility agreements is necessary to receive local WIC services. If you refuse to provide this information, the health department cannot properly assess your nutritional needs, develop a care plan, or legally issue your supplemental food benefits and WIC vouchers.

Record Series and Privacy Classification

Your consultation data will be securely maintained under the Women, Infants, and Children (WIC) women’s participant files (Series 14147) and/or the WIC children’s participant files (Series 14146). Under the Government Records Access and Management Act (GRAMA), this data is classified strictly as a Private record. Private records are legally available to the subject of the record, the parent or legal guardian of an unemancipated minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. It will be retained for 7 years after your case is closed before being securely destroyed.

Who We Share Your Data With

To fulfill your benefits and ensure program compliance, the data collected locally during your consultation is entered directly into the centralized state WIC database managed by the Utah Department of Health and Human Services (DHHS), which also audits local program financial and operational compliance. We do not share your personal data with federal agencies such as the USDA; any data used for federal program reporting or auditing is strictly anonymized. We do not use commercial third-party contractors to process this data, we do not sell your personal data to any third parties, and it is not shared with any commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on this form by contacting the Southwest Utah Public Health Department’s WIC division. Please note: Because our clinic utilizes the centralized state WIC database for all records, approved corrections to your personal data made through our office will directly update your official profile within the Utah Department of Health and Human Services WIC system.

Why We Collect Your Data and How We Use It

We collect the participant’s identifying information, including name, date of birth, age, and parent/guardian name. We also collect highly sensitive medical, health, and dietary information, including pregnancy details (gestation weeks and estimated delivery date), weight, pre-pregnancy BMI, blood work (such as hemoglobin levels), breastfeeding plans, and nutritional history. We use this information to determine your program eligibility, provide tailored nutrition education, monitor prenatal and infant health, provide breastfeeding support, and issue WIC Family Food Benefits (such as milk, cheese, and infant formula).

Consequences of Refusing to Provide Information

Providing this information is a mandatory requirement to participate in the federal Women, Infants, and Children (WIC) program. If you refuse to provide the necessary health, dietary, and identifying information, the Health Department cannot properly assess your nutritional needs or verify your eligibility. As a result, we will be unable to enroll you in the program or issue your supplemental food benefits.

Record Series and Privacy Classification

This care plan maps to the SWUPHD Retention Schedule for Women, Infants, and Children (WIC) women’s participant files (Series 14147) or WIC children’s participant files (Series 14146). Under the Government Records Access and Management Act (GRAMA), the information collected in these files is classified as a Private record. Private records are legally available to the subject of the record, the parent or legal guardian of an unemancipated minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. Women’s participant files are retained for 4 years after the end of the fiscal year of the client’s termination. Children’s participant files are retained until the child reaches the age of ten. After the approved retention period and obtaining written permission from the State, these records are securely destroyed.

Who We Share Your Data With

Because this record is classified as Private under GRAMA, your personal and health data will NOT be shared with or made available to the general public. It will be shared internally with authorized WIC staff. To coordinate care and fulfill program requirements, your personal data is entered directly into the centralized state WIC database managed by the Utah Department of Health and Human Services (DHHS). We do not share your personal data with a designated primary care physician, local pediatric clinics, or any other outside healthcare providers. We do not share your personal data with federal agencies such as the U.S. Department of Agriculture (USDA); any data used for federal program reporting is strictly anonymized. We do not use commercial third-party contractors to process this data, we do not sell your personal data to any third parties, and it is not shared with any commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on this form by contacting the Southwest Utah Public Health Department’s WIC division. Please note: Because our clinic utilizes the centralized state WIC database for all records, approved corrections to your personal data made through our office will directly update your official profile within the Utah Department of Health and Human Services WIC system.

Why We Collect Your Data and How We Use It

We collect and document the participant’s identifying information (such as name, date of birth, and Person ID) alongside specific medical and nutritional data, including your WIC category, height, weight, hemoglobin and hematocrit levels, and nutritional risk factors (such as being underweight). We also track your certification dates, income determination dates, and specific WIC food benefit issuance dates. We use this information to officially document your current certification status and eligibility in the federal Women, Infants, and Children (WIC) program, which serves as proof of your active status and authorized food benefits, particularly when you need to transfer your services to another WIC clinic.

Consequences of Refusing to Provide Information

Providing the necessary health, income, and identifying information to verify your certification is a mandatory requirement of the WIC program. If you refuse to provide this data, the Health Department cannot assess your nutritional risk or verify your continued eligibility, meaning we cannot issue a Verification of Certification, maintain your enrollment, or provide your supplemental food benefits.

Record Series and Privacy Classification

This verification document is maintained in the participant’s file and maps to the SWUPHD Retention Schedule for Women, Infants, and Children (WIC) women’s participant files (Series 14147) or WIC children’s participant files (Series 14146). Under the Government Records Access and Management Act (GRAMA), the information collected in these files is classified as a Private record. Private records are legally available to the subject of the record, the parent or legal guardian of an unemancipated minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. Women’s participant files are retained for 4 years after the end of the fiscal year of the client’s termination. Children’s participant files are retained until the child reaches the age of ten. After the approved retention period and obtaining written permission from the State, these records are securely destroyed.

Who We Share Your Data With

Because this record is classified as a Private record under GRAMA, your personal, health, and nutritional data will NOT be shared with or made available to the general public. It will be shared internally with authorized WIC staff. To administer the program and facilitate clinic transfers, your personal data is entered directly into and retrieved from the centralized state WIC database managed by the Utah Department of Health and Human Services (DHHS), making it available to other authorized clinics within the state system. For out-of-state transfers, this information is provided directly to you or the receiving clinic at your request. We do not share your personal data with federal agencies such as the U.S. Department of Agriculture (USDA); any data used for federal program reporting is strictly anonymized. We do not use commercial third-party contractors to process this data, we do not sell your personal data to any third parties, and it is not shared with any commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on this form by contacting the Southwest Utah Public Health Department’s WIC division. Please note: Because our clinic utilizes the centralized state WIC database for all records, approved corrections to your personal data made through our office will directly update your official profile within the Utah Department of Health and Human Services WIC system.

Why We Collect Your Data and How We Use It

We collect the participant’s or parent/guardian’s signature to legally authorize the release of confidential personal and medical information from your WIC record to a specifically designated person or agency. Depending on your selections, this may include highly sensitive data such as substance abuse records, HIV-related information, mental health information, hemoglobin (Hgb) levels, height and weight, and formula or food needs. We use this authorization to ensure we only share your protected health and nutritional information in accordance with your explicit instructions for coordination of care, medical referrals, or other requested purposes.

Consequences of Refusing to Provide Information

Providing this signature and authorization is voluntary. However, if you choose not to provide this authorization, the Health Department cannot legally release your requested confidential WIC records or health information to the specified person or agency, which may prevent or delay medical referrals and coordination of care.

Record Series and Privacy Classification

This release of information form is kept within the participant’s file and maps to the SWUPHD Retention Schedule for Women, Infants, and Children (WIC) women’s participant files (Series 14147) or WIC children’s participant files (Series 14146). Under the Government Records Access and Management Act (GRAMA), the information collected in these files is generally classified as a Private record. Private records are legally available to the subject of the record or the parent/legal guardian of an unemancipated minor. However, records containing mental health, psychiatric, or psychological data may be classified as Controlled if releasing them directly to you would be detrimental to your safety or violate medical ethics. Controlled records cannot be released directly to you, but may be released to a qualified medical professional (such as a physician, psychologist, or certified social worker) upon your submission of this release. Women’s participant files are retained for 4 years after the end of the fiscal year of the client’s termination. Children’s participant files are retained until the child reaches the age of ten. After the approved retention period and obtaining written permission from the State, these records are securely destroyed.

Who We Share Your Data With

Because this record is classified as Private and potentially Controlled under GRAMA, your personal and health data will NOT be shared with or made available to the general public. It will only be shared internally with authorized Southwest Utah Public Health Department and Utah Department of Health and Human Services WIC staff (being logged directly into the centralized state WIC database), and explicitly with the specific person or agency you have named and authorized on this form. We do not use commercial third-party contractors to process this data, we do not sell your personal data to any third parties, and it is not shared with any commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on this form by contacting the Southwest Utah Public Health Department’s WIC division. Please note: Because our clinic utilizes the centralized state WIC database for all records, approved corrections or revocations to this authorization made through our office will directly update your official profile within the Utah Department of Health and Human Services WIC system.

Why We Collect Your Data and How We Use It

We collect the parent or guardian’s name, Family ID, address, stated income amounts, signatures, and detailed written explanations regarding why you lack standard proof of identity, residency, or income (including details on how your family gets food if you report zero income). We use this information to serve as a legally binding affidavit to provisionally verify your eligibility for the federal Women, Infants, and Children (WIC) program when standard documentation is unavailable.

Consequences of Refusing to Provide Information

Providing this information and your signature is mandatory if you are attempting to receive benefits but do not have standard proof of identity, residency, or income. If you refuse to provide this signed statement, the Health Department cannot verify your eligibility, which will result in an inability to enroll you in the program or issue your supplemental food benefits.

Record Series and Privacy Classification

This signed statement becomes part of the participant’s record and maps to the SWUPHD Retention Schedule for Women, Infants, and Children (WIC) women’s participant files (Series 14147) or WIC children’s participant files (Series 14146). Under the Government Records Access and Management Act (GRAMA), the information collected in these files is classified as a Private record. Private records are legally available to the subject of the record, the parent or legal guardian of an unemancipated minor subject, a legal guardian of an incapacitated adult, or someone with a notarized release or power of attorney. Women’s participant files are retained for 4 years after the end of the fiscal year of the client’s termination. Children’s participant files are retained until the child reaches the age of ten. After the approved retention period, these records are securely destroyed.

Who We Share Your Data With

Because this record is classified as a Private record under GRAMA, your personal and financial data will NOT be shared with or made available to the general public. It will be shared internally with authorized WIC staff. We rely solely on the information you provide on this form; no external agencies, databases, or persons share personal data with us to cross-reference or verify your claims. To administer and audit the program, your personal data is entered directly into the centralized state WIC database managed by the Utah Department of Health and Human Services (DHHS). We do not share your personal data with federal agencies such as the U.S. Department of Agriculture (USDA); any data used for federal program reporting is strictly anonymized. We do not use commercial third-party contractors to process this data, we do not sell your personal data to any third parties, and it is not shared with any commercial entities.

Procedure to Correct Personal Data

In accordance with the Government Data Privacy Act, you or your legal guardian may request an amendment or correction of the personal data you have furnished on this form by contacting the Southwest Utah Public Health Department’s WIC division. Please note: Because our clinic utilizes the centralized state WIC database for all records, approved corrections to your personal data made through our office will directly update your official profile within the Utah Department of Health and Human Services WIC system.