AGENCY: Weber-Morgan District Health Department (Utah)

SERIES: 24556
TITLE: Tobacco education program youth referral form
DATES: 1990-
ARRANGEMENT: Chronological, thereunder alphabetical by youth's name

DESCRIPTION: This form is used by the Second District Court to refer youths who abused tobacco to the local health department to attend the tobacco education program. It includes referral date, name, age, sex, name of parent/guardian, telephone numbers (work/phone), name of school, referral source (juvenile court, municipal court, school, local police, etc); when a smoking ticket was issued, first time in class, date notified by letter and phone, date of first called, indication by class instructor of class attendance (attendance (y/n), quantity smoked/chewed, project (y/n), assignment (y/n), comments, date progress/completion certificate sent, and tracking record - 1 month, 3 month, 6 months (date, use status, and any comments).

RETENTION

Retain for 2 year(s)

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

Retention and disposition for this series is proposed and has not yet been approved.

FORMAT MANAGEMENT

Paper: Retain in Office for 2 years and then destroy.

APPRAISAL

PRIMARY DESIGNATION

Private

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