Request for Technical Assistance
This form is for community members in the San Joaquin/Central Valley who are seeking technical assistance or information to address an environmental health concern.
Name
Your answer
Phone Number
Your answer
Email address
Your answer
Are you representing a community or community-based organization?
Name of your organization
Your answer
Briefly state what you or your community are concerned about? (1-2 sentences)
Your answer
Are your concerns related to any of the following (check all that apply)?
Required
Do you know or have an idea where the problem might be coming from? (Examples include, but are not limited to a highway, factory, waste facility, farm or dairy).
Please provide a brief description of the source and the address or approximate location (if known).
Your answer
Are you worried about a particular disease or illness?
Please describe any specific health concerns you or your community have that you think may be related to the environmental problem.
Your answer
How did you hear about the Environmental Health Sciences Center? If you have communicated with any UC Davis researchers about this problem, please let us know who you have been in contact with.
Your answer
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