Data Request Form

"*" indicates required fields

Instructions for the Requester:

Please complete the form below by responding to the following fields. If you would like to download a PDF version to fill out manually and email, please scroll to the bottom of this page. For post submissions, please check your spam folder on your email in case emails are redirected there.

Requestor Details

Name*

First Last

Email*

Phone*

Data Request Details

Topic of interest*

Cancer

Diabetes

Cardiovascular disease

Tobacco

HIV

Sexually transmitted infections (STIs)

Tuberculosis (TB)

Respiratory illness

Substance use

Mental Health

Other

If 'other' please describe below:

Purpose*

Describe the purpose of the data or analysis. What would you like us to help you with?

Date data/analysis needed by:*

(Data analysis requests can take 1-3 months to complete, depending on the volume of requests.)

Month

Day

Year

When requestor is available to meet:*

Please list all dates, or date ranges that meet your availability (MM/DD/YYY).

Looking to submit your request manually?

Please click on the PDF Thumbnail to the right to download our fillable document. Once fully filled out, please email the attachment to:

DRTA@npaihb.org

Note: NPAIHB.ORG is undergoing maintenance at this time, please be aware that not all pages will be available.

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