Data Request Sent	Click here to enter a date.	Proposed Request Deadline*	Click here to enter a date.
*NOTE: Data requests are processed as quickly as possible; however, due to staffing and complexity of the requests it can take longer. Please provide as much detail as possible to expedite the process. If you have examples of previous data requests or graphs, please attach.
Requestor Information
Name	Title & Organization
Phone	Email
Description of Data Request
Background Information and/or Question
Intended audience
Data Sets (if known)	Behavioral Risk Factor Surveillance System (BRFSS) Hospital Discharge (ED and Hospitalizations) Mortality Asthma Call Back Survey Other –specify
Purpose of Request
Purpose	Analysis or support for decision-making activities (i.e., policies, program changes) Grant materials and evidence Quarterly, semi-annual or annual report	Presentation Research project Other –specify
Please describe the purpose in detail:
Parameters
Time Period	CY = Calendar Year (e.g., CY12 = 01/01/12 – 12/31/12) SFY = State Fiscal Year (e.g., SFY12 = 07/01/12 – 06/30/12) FFY = Federal Fiscal Year (e.g., FFY12 = 10/01/12 – 09/30/12)
Geography	Statewide (aggregate), by County, Other
Specific Demographics	Age, Sex, Race, Ethnicity, Other
Diagnosis Codes	List ICD codes as appropriate

[FOR INTERNAL USE ONLY]

NOTES