Data Request Form

The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Required format:

Please complete one form for each individual data request. All required fields are denoted by a red asterisk (*); it is not possible to submit the form without completing all required fields.

Data will be released in accordance with the Alabama Department of Public Health's privacy and data release policies.

Date of Request

M-D-Y

First Name

* must provide value

Last Name

* must provide value

Organization

* must provide value

Title/Position within Organization

* must provide value

Phone Number

* must provide value

Are you the primary contact for this request?

* must provide value

Yes

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Primary Contact Information (Only complete this section if you are not the primary contact)

First Name

Last Name

Organization

Title/Position within Organization

Phone Number

Are you the principle investigator/main researcher for this project?

* must provide value

Yes

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Principle Investigator/Main Researcher Information (Only complete this section if you are not the principle investigator)

First Name

Last Name

Organization

Title/Position within Organization

Phone Number

Which subject matter area(s) does your data request include?

* must provide value

COVID-19 Disease

Environmentally-Transmitted Diseases

Foodborne Diseases

Healthcare-Associated Infections

Influenza/Influenza-Like Illnesses (ILI)

Mycotic Diseases

Outbreaks

Respiratory Diseases (other than COVID-19 and influenza/ILI)

Syndromic Surveillance

Vectorborne Diseases

Waterborne Diseases

Zoonotic Diseases

Other Not Listed

If other not listed, please specify subject matter area(s):

* must provide value

Brief Description of Requested Data

* must provide value

Expand

Geographic Area(s) of Interest

* must provide value

Statewide

By Public Health District

Other

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If other geographic area(s), please describe

Public Health District(s)

All Public Health Districts

East Central

Jefferson

Mobile

Northeastern

Northern

Southeastern

Southwestern

West Central

Time Period - Begin Date

* must provide value

M-D-Y

Time Period - End Date

* must provide value

M-D-Y

Data Stratified By

Data Requested By

* must provide value

M-D-Y

Alabama Department of Public Health
Terms and Conditions

Restricted data include any and all information created or received by the Alabama Department of Public Health (ADPH) that relates to: the past, present, or future physical or mental health or condition of an individual; the provision of health services to an individual; the past, present, or future payment for the provision of health services to an individual; or certain environmental, health engineering, or toxicological data derived from individually-owned dwellings, land, or businesses; and that allows for the direct or indirect identification of that individual.

Restricted data will only be released to external users after the ADPH program designee(s) responsible for managing data requests has reviewed the request. The request must include a completed data request form, acknowledgement of the Terms and Conditions, and an IRB application form (as applicable).

To the extent that a unit of the ADPH is considered a covered entity within the meaning of the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-91, codified at 42 U.S.C. §§ 1320 (d)(1)-(d)(8)), the applicable standards, rules, and regulations established under that statute are applicable to the data collected by that particular ADPH unit.

If it is determined that part or all of a data request can be accomplished through in-house analysis, use of unrestricted data, or the creation of proxy variables, the ADPH reserves the right to create such products to fill a request, rather than release the restricted data.

It is understood that the provided information is to be used solely for the purpose stated on this form. No individual- or institution-specific information will be released. County-level data is the lowest geographical level that can be released and even then only if the number of cases is above a certain threshold, as defined by data suppression guidelines. Any researcher requiring confidential data (i.e. Patient name, date of birth, social security number, etc.) must complete a separate application and subsequently receive approval from the Alabama Department of Public Health, Institutional Review Board (IRB).

ADPH is committed to the protection of human subjects participating in public health research and assuring that the rights and welfare of human participants in research are protected in the conduct of all public health activities.

* must provide value

I have read and agree to the Terms and Conditions.

ADPH IRB Application

Attachment:IRB Approval Form.doc

You may upload up to three supporting documents. How many would you like to upload?

* must provide value

Supporting Document 1

Upload file

Supporting Document 2

Upload file

Supporting Document 3

Upload file

Verify Data Request

Before submitting this data request, please review the summary below and verify it is accurate. If everything is correct, click the 'Submit' button below.

Date of Submission	______
Requested By	______ ______
Primary Contact	______ ______, ______
Data Request Details	Description: ______; Time Frame: ______ - ______; Area: ______
Preferred Completion Date	______

Date Request Reviewed

M-D-Y

Name of Reviewer

Legal Consulted (if not needed, select 'N/A')

Request Forwarded to Appropriate Person(s)

Yes

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Bureau Request Was Forwarded To

If other, please specify

Name of Person Who Received the Request

Is an alternate delivery date needed?

Yes

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If yes, specify alternate delivery date

Date Request Completed & Sent

M-D-Y

Comments

You may upload up to three supportive files for this request.

How many would you like to upload?

File 1

Upload file

File 2

Upload file

File 3

Upload file

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