Health & Safety Opt-Out Form JavaScript Required You must have JavaScript enabled to use this form. Please enable JavaScript and reload the page. If you cannot enable JavaScript, please contact webadmin@cityofmadison.com to provide your information. The City of Madison collects information and maintains records relating to members of the public. The City places some of this information online where anyone with Internet access can view it. Once information or records have been released on the Internet, they may continue to be available on the Internet even after the City has removed them from its website. By completing this form, you are requesting that the City make a good faith effort to withhold your personally identifiable information from being publicly available on the City website due to concerns over your life, health, or safety.The City will notify you in writing as to whether your request has been approved or denied. Name * required How would you like us to contact you? * required Email Phone Email Phone Request to withhold information What records have your information? * required Please let us know what City departments or services you worked with. Example: I worked with the Clerk's Office to get a bartender's license. Where is your information found? Let us know the web address of pages on the City of Madison website where you found your information.Example: https://www.cityofmadison.com/assessor/property/ What information are you requesting to be withheld? Help us understand the specific information you would like withheld. Examples might include name, address, or phone number. Why is this information a concern to your life, health, or safety? * required You may be asked to provide documentation that supports your request. Agreement Signature * required Please type your name. Date * required Leave this field blank JavaScript Required You must have JavaScript enabled to use this form. Please enable JavaScript and reload the page. If you cannot enable JavaScript, please contact webadmin@cityofmadison.com to provide your information. Was this page helpful to you? * required Yes No Why or why not? Leave this field blank Strategic Priorities Privacy Expanded Health & Safety Opt-Out Form
