*1.Please provide  the following information:(Required.)

First Name, Last Name:  *

Employee/ Contract Number:

County Email Address: *

Best Phone Number:

*2.DHS Facility/ Department do you work at?(Required.)

LACUSC 

HUCLA

OVMC

RLA

ACN

MLK Outpatient Center 

CHS

JCHS

MCS

EMS

HSA/DHS Central Units and Other Program Units

Other (please specify)