Local Health Officer Contact Information Form

To update your Local Health Officer Contact information, please complete the form below. Note:  All fields must be completed. An incomplete form will be returned to you to fill-in the missing information.  After completing the form, please click on the submit button. The Division of Local Public Health will update your information. If you are required to submit a Letter of Appointment from your town, please email the letter to judy.gopaul@maine.gov, or by U.S. Mail to Maine Center for Disease Control and Prevention, Division of Local Public Health, 286 Water Street, 7th Floor, SHS 11 Augusta, Maine 04333.   Thank you!

Town's official letter of your appointment:
If YES, please send a copy of your signed letter of appointment either by email to: judy.gopaul@maine.gov or by U.S. Mail to: Division of Local Public Health, Maine Center for Disease Control & Prevention 286 Water Street, 7th Floor, SHS 11, Augusta, Maine 04333. You may also fax your letter to Judy Gopaul at 207-287-5355. This office will only issue a Certificate of Completion upon receipt of your letter of appointment.
On-line Training: Have you completed the LHO mandatory on-line self-paced training?


State Employee: Are you a state employee?:
Other Roles: Are you employed by your town government in another role (other than the LHO)?:

 
It is important that you include your email address, as you will receive your Certificate of Completion for this mandatory training via the email address you provide.

Please note also, that in order to receive your certification of completion, the Division of Local Public Health must receive your town's letter of appointment within 10 working days from completion of the on-line training, or your appointment.
    

Problems?

If you have any problems using this form, or do not receive a confirmation e-mail, contact Judy Gopaul