Data Request Form 2006
Download a blank fillable Data Request Form 2006 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Data Request Form 2006 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1This form is to be used in conjunction with Adobe Reader. The form can be completed online then printed and faxed to the Dutchess County Department of
Behavioral & Community Health. See the bottom of this form for fax information.
Dutchess County Department of Behavioral & Community Health
Data Request Form
Name:
Organization/Department:
Address:
Phone Number:
Fax Number:
E-mail:
Date of Request:
The following information is to assist our Biostatisticians in completing your request.
1. What is the purpose of your request? Please check appropriate box and then explain.
Research
Grant writing
School project
Other (specify)
Explain:
2. What variables do you need (e.g., births, deaths)?
3. What time period are the data for (e.g., most recent year, multiple years, sequential/aggregate)?
4. Define your population:
Age:
Race/Ethnicity:
Gender:
Other (specify):
5. What is/are the geographic area(s) for the requested data?
County:
Municipality (specify):
Other (specify)
6. What format do you need the variables in (e.g., numbers, percentages)?
Please allow up to two weeks for processing of your request. Also note that individually
identifiable health information is protected under the Health Information Procurement
Accountability Act (HIPAA) and cannot be released.
Internal Office Use:
Received by:____________________________________Date received:____________________________
Reviewed with:__________________________________Date reviewed:___________________________
Approved by:____________________________________Date:__________________________________
Completed by:___________________________________Date Completed:_________________________
Dutchess County Department of Behavioral & Community Health – 85 Civic Center Plaza - Suite
106, Poughkeepsie, NY 12601 Fax: 845-486-3561
Email: healthinfo@co.dutchess.ny.us
Print
Reset Form
Rev 2/17/06
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal