# Title 23 — Health and Safety

## Chapter 23-35 — Public Health Units

### § 23-35-01. Definitions.

As used in this chapter, unless the context otherwise requires:
1. "Board of health" means a district, county, city, or tribal board of health.
2. "Department" means the department of health and human services.
3. "Governing body" means, as applicable, a city commission, city council, board of
county commissioners, joint board of county commissioners, or tribal council.
4. "Health district" means an entity formed under section 23-35-04 or 23-35-05.
5. "Joint board of county commissioners" means the boards of county commissioners of
two or more counties acting together in joint session.
6. "Local health officer" means the health officer of a public health unit.
7. "Public health department" means a city, county, or tribal health department formed
under this chapter.
8. "Public health unit" means the local organization formed under this chapter to provide
public health services in a city, county, or designated multicounty or city-county area,
or Indian reservation. The term includes a city public health department, county public
health department, tribal health department, and a health district.
### § 23-35-02. Public health units - Core functions.

1. All land in the state must be in a public health unit.
2. At a minimum, a public health unit shall provide the following core functions:
a. Communicable disease control, which must include:
(1) Conducting of disease surveillance for the purpose of preventing and
controlling communicable disease, with assistance from the department.
(2) Assurance of the availability of community-based programs to provide
communicable disease prevention and control services.
(3) Recognition, identification, and response to a communicable disease event,
in collaboration with the department.
b. Chronic disease and injury prevention, which must include conducting programs
to reduce the burden of chronic disease and injury through policy, system, and
environmental change approach; prevention screening; and education.
c. Environmental public health, which must include:
(1) Prevention of environmental hazards by the provision of information and
education to facility operators and managers and to community members.
(2) Assurance of the availability of environmental health services to prevent and
respond to community and residential environmental hazards.
(3) Permitting and inspections of onsite wastewater treatment systems in
accordance with chapter 23.1-07.1. A public health unit shall conduct a
required in-person or virtual inspection of an onsite wastewater system
within one business day of receiving the request for the inspection. A public
health unit may enter a cooperative agreement with a county or city for the
permitting and inspection of onsite wastewater treatment systems within the
boundaries of the county or city. A cooperative agreement may be
terminated as provided in the agreement, by joint action of all parties, or by
an individual party no less than one year after providing written notice to the
other party.
d. Maternal, child, and family health, which must include:
(1) Assessment and monitoring of maternal and child health status to identify
and address problems.
(2) Implementation of programs to promote the health of women, children, and
youth, and their families, through policy, system, and environmental change
approaches; prevention screenings; and education.
e. Access to clinical care, which must include:

(1) Collaboration with health care system partners to foster access to clinical
care.
(2) Facilitation of linkages and referrals for appropriate clinical care, services,
and resources.
### § 23-35-02.1. Tribal health units.

An Indian nation that occupies a reservation the external boundaries of which border more
than four counties may form a health district or public health department as provided in this
chapter. A tribal public health unit and bordering public health units shall collaborate regarding
the provision of public health services. If an individual who is not an enrolled member of an
Indian tribe of the Indian reservation that forms a tribal public health unit is a party to a civil
action in which the tribal public health unit is also a party, that individual may bring the action in
or move the action to tribal court or district court.
### § 23-35-02.2. Public health units to adopt onsite wastewater recycling treatment guide.

Repealed by S.L. 2025, ch. 248, § 4.
### § 23-35-02.3. Onsite wastewater recycling technical committee - Appointment - Duties.

Repealed by S.L. 2025, ch. 248, § 4.
### § 23-35-03. Boards of health.

1. The department shall advise boards of health.
2. A city's, county's, or tribe's governing body may establish a public health unit by
creating and appointing a board of health, which in the case of a city, may be
composed of the city's governing body, or in the case of a tribe, may be composed of
the tribal council or governing body. A board of health must have at least five
members.
a. In the case of a board of health created by a joint board of county commissioners,
each county in the health district must have at least one representative on the
board; each county of over fifteen thousand population must have an additional
representative for each fifteen thousand population or major fraction of that
number; and in a health district of fewer than five counties, each county must
have at least one representative on the district board of health, and the additional
representatives selected to constitute the minimum five-member board must be
equitably apportioned among the counties on a population basis.
b. In the case of a joint city-county health district composed of only one county and
having at least one city over fifteen thousand population, each city having a
population over fifteen thousand must have a representative on the district board
of health for each fifteen thousand population or major fraction of that number,
and the remaining population of the county, exclusive of the populations of cities
with more than fifteen thousand each, must have a representative on the district
board of health for each fifteen thousand population or major fraction of that
number, or at least one member if the remaining population is less than fifteen
thousand.
3. The initial members of any board of health appointed by a governing body must be
appointed for terms as follows: at least one for one year, one for two years, one for
three years, one for four years, and one for five years. If a board has more than five
members, the members must be appointed for staggered terms. All subsequent
appointments are for five-year terms. Each board member shall serve until a
successor is appointed and qualified. If a vacancy occurs, the appointing government
authority shall appoint a member for the remainder of the unexpired term. Each
appointee shall qualify by filing the oath of office. A board of health may not be all male
or all female. If the members of a governing body serve on a board of health or if an
employee of a governing body serves on a board of health, this subsection does not
apply to those governing body members and that employee.

4. A board of health shall meet at least quarterly. Special meetings may be held at any
time at the call of the president.
5. Except if the governing body serves as the board of health, at the first meeting after
appointment, and annually, the members of a board of health shall organize by
electing a president, a vice president, and other officers the board considers
necessary. If there is a treasurer and the treasurer is not a public employee, the
treasurer must be bonded in an amount fixed by the board. If the health officer is not
appointed to the board, the health officer does not have a vote in matters of the board.
The office of secretary and treasurer may be combined.
6. The appointing authority shall establish the rate of compensation for board members
and actual expenses incurred by board members may be reimbursed at the official
reimbursement rates of the appointing authority.
### § 23-35-04. Health districts - Formation - Contracting for services.

1. Upon the adoption of a resolution, the governing body may form a single county,
multicounty, city-county, or tribal health district.
2. Notwithstanding this chapter, in a county without a countywide public health unit, the
board of county commissioners, upon adoption of a resolution, may contract with a city
that has a public health department to provide health services to the county and in the
cities throughout the county which do not have a public health unit. The contract must
comply with chapter 54-40.3. When a contract is executed, any provision of this
chapter relating to organizing district boards of health does not apply, and the city
public health department shall exercise all the necessary powers and duties of a public
health unit under this chapter. The department shall treat a county with a contract
under this subsection as a public health unit.
### § 23-35-05. Health districts - Expansion - Merger.

1. Upon adoption of a resolution, a county that is not included in any public health unit
may request inclusion as a part of an existing health district. Upon receipt of a request
to become part of an existing health district, the district board of health shall consider
the request and, if the board approves the request by a majority vote, shall submit the
matter to each county in the health district. If a majority of the counties approve the
request by a majority vote, the requesting county becomes a part of the health district.
2. Upon expansion of a health district under this section, the number of board of health
members must be adjusted to allow the added county the same proportion of
members allowed to member cities and counties of the existing health district as
determined under this chapter.
3. Any two or more health districts may merge into a single health district upon a majority
vote of the respective boards of health and a majority vote of the governing body of
each county. The assets of each merging health district become the property of the
newly created health district. Board of health membership of a new health district must
be determined under section 23-35-03, unless otherwise decided by the board. The
new health district maintains the same authority and powers of the previous health
districts. The mill levy of the newly created health district is not limited by the old mill
levy but may not exceed the amount allowed under section 23-35-07, unless one or
more of the combining entities was previously levying more than five mills, in which
case the mill levy for property within the former entity that was levying more than five
mills may not exceed the cap, expressed in mills, as previously authorized for that
entity.
4. Upon adoption of a health district plan by two or more counties, the joint board of
county commissioners shall appoint a district board of health.
### § 23-35-06. Health districts - Dissolution - Withdrawal.

1. Except for a tribal health district, if a health district has been in operation for two years,
the district may be dissolved as provided for under this section. If a petition is filed with

the county auditor of each county of a health district which is signed by qualified
electors of that county equal to ten percent or more of the votes cast in that county at
the last general election, an election on the question of dissolution must be presented
to the qualified electors in each county in the district at the next election held in each
county in the district. If a majority of the votes cast on the question in a majority of the
counties favor dissolution, the health district is dissolved on the second January first
following the election. If a majority of the votes cast on the question in a majority of the
counties are against dissolution, no other election on this issue may be held for two
years.
2. If a health district has been in operation for two years, any county may withdraw from
the district as provided under this section. If a petition is filed with the withdrawing
county's auditor which is signed by qualified electors of the county equal to ten percent
or more of the votes cast in that county at the last general election, an election on the
question of withdrawal must be presented to the qualified electors in the county at the
next election in the county. If a majority of the votes cast on the question favor
withdrawing from the district, the county is withdrawn from the district on the second
January first following the election. If a majority of the votes cast on the question are
against withdrawal, no other election on this issue may be held for two years.
3. A tribal health district may be dissolved by the tribal council or governing body at any
time.
### § 23-35-07. Health district funds - Financial report.

1. Except for a tribal health district, a district board of health shall prepare a budget for
the next fiscal year at the time at which and in the manner in which a county budget is
adopted and shall submit this budget to the joint board of county commissioners for
approval. In the year for which the levy is sought, a district board of health, except for
a tribal health district, seeking approval of a property tax levy under this chapter must
file with the county auditor of each county within the health district, at a time and in a
format prescribed by the county auditors, a financial report for the preceding calendar
year showing the ending balances of each fund held by the health district during that
year. The amount budgeted and approved must be prorated in health districts
composed of more than one county among the various counties in the health district
according to the taxable valuation of the respective counties in the health district. For
the purpose of this section, "prorated" means that each member county's contribution
must be based on an equalized mill levy throughout the district, except as otherwise
permitted under subsection 3 of section 23-35-05. Within ten days after approval by
the joint board of county commissioners, the district board of health shall certify the
budget to the respective county auditors and the budget must be included in the levies
of the counties. The budget, not including gifts, grants, donations, and contributions,
may not exceed the amount that can be raised by a levy of five mills on the taxable
valuation, subject to public hearing in each county in the health district at least fifteen
days before an action taken by the joint board of county commissioners. Action taken
by the joint board of county commissioners must be based on the record, including
comments received at the public hearing. A levy under this section is not subject to the
limitation on the county tax levy for general and special county purposes. The amount
derived by a levy under this section must be placed in the health district fund. The
health district fund must be deposited with and disbursed by the treasurer of the
district board of health. Each county in a health district quarterly shall remit and make
settlements with the treasurer. Any funds remaining in the fund at the end of any fiscal
year may be carried over to the next fiscal year.
2. Except for a tribal health district, the district board of health, or the president and
secretary of the board when authorized or delegated by the board, shall audit all
claims against the health district fund. The treasurer shall pay all claims from the
health district fund. The district board of health shall approve or ratify all claims at the
board's quarterly meetings.

### § 23-35-08. Boards of health - Powers and duties.

Except when in conflict with a local ordinance or a civil service rule within a board of health's
jurisdiction, or a tribal code, ordinance, or policy, each board of health:
1. Shall keep records and make reports required by the department.
2. Shall prepare and submit a public health unit budget.
3. Shall audit, allow, and certify for payment expenses incurred by a board of health in
carrying into effect this chapter.
4. May accept and expend any gift, grant, donation, or other contribution offered to aid in
the work of the board of health or public health unit.
5. May make rules regarding any nuisance, source of filth, and any cause of sickness
which are necessary for public health and safety, except rules regarding the licensing
of onsite wastewater treatment system installers.
6. May establish by rule a schedule of reasonable fees that may be charged for services
rendered. Services may not be withheld due to an inability to pay any fees established
under this subsection. If a tribal board of health establishes fees for services rendered,
the fees may not exceed the highest corresponding fee of any of the public health
units that border the tribal public health unit.
7. May make rules in a health district or county public health department, as the case
may be, and in the case of a city public health department may recommend to the
city's governing body ordinances for the protection of public health and safety.
8. May adopt confinement, decontamination, and sanitary measures in compliance with
chapter 23-07.6 which are necessary when an infectious or contagious disease exists.
9. May make and enforce an order in a local matter if an emergency exists.
10. May inquire into any nuisance, source of filth, or cause of sickness.
11. Except in the case of an emergency, may conduct a search or seize material located
on private property to ascertain the condition of the property as the condition relates to
public health and safety as authorized by an administrative search warrant issued
under chapter 29-29.1.
12. May abate or remove any nuisance, source of filth, or cause of sickness when
necessary to protect the public health and safety.
13. May supervise any matter relating to preservation of life and health of individuals,
including the supervision of any water supply and sewage system.
14. May isolate, kill, or remove any animal affected with a contagious or infectious disease
if the animal poses a material risk to human health and safety.
15. Shall appoint a local health officer.
16. May employ any person necessary to effectuate board rules and this chapter.
17. If a public health unit is served by a part-time local health officer, the board of health
may appoint an executive director. An executive director is subject to removal for
cause by the board of health. The board of health may assign to the executive director
the duties of the local health officer, and the executive director shall perform these
duties under the direction of the local health officer.
18. May contract with any person to provide the services necessary to carry out the
purposes of the board of health.
19. Shall designate the location of a local health officer's office and shall furnish the office
with necessary equipment.
20. May provide for personnel the board of health considers necessary.
21. Shall set the salary of the local health officer, the executive director, and any assistant
local health officer and shall set the compensation of any other public health unit
personnel.
22. Shall pay for necessary travel of the local health officer, the local health officer's
assistants, and other personnel in the manner and to the extent determined by the
board.
### § 23-35-09. Abatement and removal of nuisance, source of filth, and cause of sickness.

1. If necessary for the protection of public health to abate or remove any nuisance,
source of filth, or cause of sickness, the board of health shall serve notice on the

owner or occupant of the property requiring the owner or occupant, at the owner's or
occupant's expense, to remove or abate the nuisance, source of filth, or cause of
sickness within a time specified by the board, not exceeding thirty days. If the owner or
occupant fails to comply with the notice to remove or abate or if the nuisance, source
of filth, or cause of sickness exists on property of nonresident owners or on property
the owners of which cannot be found, the board of health may remove or destroy the
nuisance, source of filth, or cause of sickness at the expense of the appropriate city or
county, which shall charge the expense against the lot, piece, or parcel of land on
which the work is done.
2. The governing body of the city or county may levy and assess against the property the
cost of the removal or destruction of a nuisance, source of filth, or cause of sickness,
and the member of the governing body who is responsible for streets shall return and
file the assessment in the office of the auditor of the city or county. The auditor shall
publish, in the same manner as provided under section 40-22-06, the amount of the
assessment together with a notice of the time and location the governing body will
meet to consider the approval of the assessment. Each assessment must be recorded,
collected, and paid as other taxes are recorded, collected, and paid.
3. If a board of health determines it necessary for the preservation of public health to
enter any building within the board's jurisdiction to examine, destroy, remove, or
prevent any nuisance, source of filth, or cause of sickness and is refused entrance into
the building, the local health officer, or a designated agent of the local health officer,
may make a complaint under oath to a district judge within the jurisdiction of the board
of health stating the facts in the case which the local health officer, or a designated
agent of the local health officer, has knowledge. If a warrant is issued and if requested
by a board of health, a county sheriff or city police department shall provide assistance
to that public health unit in any action to search or seize material in or on any private
property to destroy, remove, or prevent the nuisance, source of filth, or cause of
sickness, if there is probable cause to believe a public health hazard or public health
nuisance exists on or in that property, and shall carry out any other preventive
measures the public health unit requests. For purposes of this subsection, a request
from a public health unit means a request for assistance which is specific to a public
health nuisance and is not a continuous request for assistance.
### § 23-35-10. District boards of health - Acquiring and disposing of property.

1. A district board of health may acquire by lease, purchase, construction, or gift for
district health office use and control property for all purposes authorized by law or
necessary to the exercise of the powers granted in this chapter. The district board of
health may finance the purchase, construction, or equipping of a building on owned or
leased property for the use and purpose for which the health district is formed and
carry out the functions of the health district in either of the following ways:
a. The district board of health may issue and sell bonds in an aggregate amount not
exceeding two times the authorized tax revenues of the district for the year in
which the bonds are to be issued and sold; or
b. The district board of health may mortgage or otherwise encumber the building
constructed in an amount not exceeding two times the authorized tax revenue of
the district for the year in which the construction is to be commenced.
2. Bonds issued under this section and income under this section are exempt from any
taxes except inheritance, estate, and transfer taxes. The indebtedness for which the
bonds are issued, or for which a mortgage may be given as under this section, is
neither an obligation or an indebtedness of this state nor of the counties or cities
comprising the district board of health. Any indebtedness under this section may be
foreclosed in any manner provided by law. The district board of health may convey or
transfer property acquired as provided under this section. If, upon dissolution of a
health district, any balance remains in the health district fund after all obligations have
been paid, the balance must be transferred to the general fund of the counties
comprising the health district in proportion to the assessed valuation most recently

used in preparing the health district budget under this chapter. If any county in the
district withdraws from a health district, any assets and inventory of supplies and
equipment located in the county for use in health district programs and services
remain the property of the district for use elsewhere in the district.
### § 23-35-11. Budget.

A city, county, or health district, as the case may be, shall prepare a county public health
unit budget for the next fiscal year at the time and in the manner a county budget is adopted and
submit the budget to the board of county commissioners for approval, shall prepare a city public
health unit budget for the next fiscal year and submit the budget to the governing body of the
city for approval, or shall prepare a district budget as provided under this chapter. In the case of
a city board of health, the board shall certify the expenses to the governing body for payment
out of the general fund of the city. The governing body or auditor shall audit any expenses
incurred in quarantining or disinfecting any property outside an incorporated city and shall pay
for any expenses out of the general fund of the county.
### § 23-35-12. Local health officers.

1. A local health officer shall serve a term of five years, subject to removal for cause by
the governing body or the district board of health. The health officer must be a
physician licensed to practice medicine in this state and need not be a resident of the
public health unit. The appointee shall qualify by filing the constitutional oath of office
in the manner provided for the members of the board of health. If the state health
officer finds a local health officer is failing to perform the duties of the position, the
state health officer may report the case to the governing body of the appropriate city,
county, or district board of health. At the next meeting of the city's or county's
governing body or district board of health, the governing body or district board of
health shall declare the office vacant and may appoint another physician to fill the
unexpired term, or shall report the matter to the board of health, and the board shall
declare the office vacant and promptly shall appoint another physician to fill the
unexpired term.
2. Within the jurisdiction of the board of health, a local health officer:
a. Shall keep a record of the official acts of the local health officer.
b. Shall enforce every law and rule relating to preservation of life and health of
individuals.
c. May exercise the powers and duties of the board of health under the supervision
of the board of health.
d. May make sanitary inspections of any place within the jurisdiction in which the
local health officer finds a probability a health-threatening condition exists.
e. May investigate public water and ice supplies suspected of contamination and
initiate necessary condemnation proceedings.
f. May enforce school cleanliness; inspect any school that may be overcrowded,
poorly ventilated, or unsanitary; and, when necessary, report cases of any
unsanitary or unsafe school building to the board of health for investigation.
g. May take any action necessary for the protection of public health and safety.
h. May determine when confinement and decontamination is necessary for the
safety of the public. The local health officer may establish confinements
consistent with procedures provided under chapter 23-07.6 and perform any acts
required for decontamination when necessary.
i. Shall maintain an office within the jurisdiction of the public health unit consistent
with any terms of appointment.
j. May select and discharge any assistant health officer in the public health unit,
consistent with any terms of appointment.
3. A local health officer may request the assistance of a county sheriff or city health
department in the same manner as provided under subsection 3 of section 23-35-09.

### § 23-35-13. Penalty.

A person who violates any order, ordinance, or rule prescribed by any board of health or
health officer or any rule adopted under this chapter is guilty of a class B misdemeanor.
