Data Request Form: STD/HIV/TB Section, Epidemiology and Surveillance Unit

Please note: Requests may not be completed by requested due date if surveillance staff are given less than 2 weeks to complete the analyses. Epi/surveillance staff will be in touch with you to negotiate/confirm a final date for product delivery and to clarify any questions.

For data regarding diseases other than STDs, see Diseases and Conditions Statistics.

Data Request Form

Requestor First Name



Requestor Last Name



Organization or Affiliation



Phone



E-mail



Type of request (analysis, presentation, other):



Please specify if other type:



Data set:



Please specify if other data set:

(For diseases other than STDs, see Diseases and Conditions Statistics)

Target audience (grant, community group): Please specify.

 

Requested date of completion:



*Please note, requests may not be completed by requested due date if surveillance staff are given less than 2 weeks to complete the analyses. Epi/surveillance staff will be in touch with you to negotiate/confirm a final date for product delivery and to clarify any questions.

Comments:


If you have the original grant request and/or an example of previously completed work after which you wish to have your product modeled, please state so in this area. You may be asked to email it.

To prevent abuse of this form, please type
the following letters/numbers
M9RST
into the field below. Thank you.
REQUIRED



If you have technical difficulties with this form, contact Kathy Melaas at (651) 201-4001, email.

Last Modified: 24-Jul-2014 03:09:07 pm