Welcome

Requestor Information

Name

Position

Organization

Address

Telephone (ext.)

Email

Date you require data

Please note: typical process takes between 4-6 weeks for AGG requests depending on complexity

Are you a student?

Yes

No

Type of data

Aggregate

Record Level

To be determined

Detailed description of data request

Will the data requested be used as part of any type of research?

Yes

No

Primary purpose for the data requested (for research - provide a well-defined study purpose or list of objectives)

Data will be used for (check all that apply):

Evaluation

Quality Improvement/Assurance

Policy Development

Surveillance

Research

Other

Will the data be shared publicly?

Yes

No

If yes, provide a plan for disseminating results

Additional comments:

Have you requested similar data in the past?

Yes

No