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The Personal Information on this form is collected under the authority of the Health Protection and Promotion Act and applicable privacy legislation. This information will be used for the delivery of public health programs and services and may be used for evaluation or statistical/research purposes. Any questions about the collection of this information should be directed to: ESTPH Privacy Officer, Elgin St. Thomas Public Health, 99 Edward Street, St. Thomas, ON N5P 1Y8, Telephone: (519) 631-9900; Fax: (519) 631-3745; E-mail:
estph@elginhealth.on.ca