Individual and Organization Requestor Information

1. Contact Person (person requesting data)

*Name

Title

Organization

*Address

*Email Address

*Telephone No: Fax No.

2. Overall Responsible Party

Name

Telephone No: Fax No:

3. Date Request Made:

4. Date Info Needed :

Completion of the request will depend upon the complexity of the data search and/or data analysis.

The Division of Disease Surveillance is the lead program in the collection, analysis and interpretation of public health Disease Surveillance surveillance data, specifically, notifiable diseases and/or conditions. Requests for data from external stakeholders are ongoing and the Request for Data form represents a process to monitor the nature and quality of requests. This form also provides an opportunity to critically review the type of data requests received and will engage the requestor to consider the need and justification for requesting the data.

This information will assist DID to prepare and develop useful statistical reports and provide additional resources to external stakeholders for timely processing of all requests for public health Disease Surveillance surveillance information.

Note: it is sometimes necessary to combine data from multiple years to produce reliable statistics that do not conflict with confidentiality considerations. This is likely to be necessary for events that occur infrequently. Would your request still be useful if data from multiple years were grouped together?

Note: it may be impossible to release data at the town level, depending on the data set, the size of the city/town, and whether or not it would be acceptable to have multiple years of data combined, because of the need to maintain confidentiality.

10. Format in which analysis should be sent:

Paper Report
Electronic file (spreadsheet)
Email
Other Specify