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HIV/STD Data Request Form

This policy applies to all information requests for the HIV Surveillance Branch and the Division of STD.

1. The OHPC publishes statistics at http://www.alabamapublichealth.gov/hiv while the Division of STD publishes information at https://www.alabamapublichealth.gov/std front page and Statistics link. Please review the website for available published statistics prior to submitting a data request.

2. Requests should be made by submitting the following HIV Data Request Form.

3. Requests should be submitted directly by the interested party, not their designee. Staff will respond verbally or in writing, with supporting documentation, when appropriate.

4. Clarify the information that is being requested and state how the data will be utilized in the HIV/STD Data Request Form.

5. Please submit requests related to grants as soon as possible as grant requests often require additional time to analyze and compile (i.e., thoroughly read grant guidance to identify required statistics and initiate data requests prior to beginning narrative components).

6. Please be very clear regarding the full extent of statistics requested so that data requests can be answered in a timely manner. The OHPC and Division of STD reserve the rights to limit data analysis and compilation to two requests each six months or per grant period. To ensure the correct information is being requested, HIV data requests may be discussed with the Coordinator of HIV Surveillance at (334)206-6409 or olubukola.alonge@adph.state.al.us and STD data requests can be discussed with the Director of the Division of STD at (334)206-2765 or anthony.merriweather@adph.state.al.us.

7. The OHPC and the Division of STD will make every effort to provide answers as soon as possible. A minimum of 10 business days should be allotted for completion of all data requests. Special circumstances will be considered on a case by case basis for requests not complying with the 10 business day deadline.

8. To protect the privacy of persons with HIV in Alabama, the OHPC and the Division of STD reserve the right to only release total numbers of HIV/STD cases by county when the total number of reported cases is five or more. Selected variables may only be given for counties having 50 or more cases.

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.

Date of Request

* must provide value

M-D-Y

First Name

* must provide value

Last Name

* must provide value

Organization

* must provide value

Title/Position within Organization

* must provide value

Street Address

* must provide value

City

* must provide value

State

* must provide value

Zip

* must provide value

Phone Number

* must provide value

Fax

* must provide value

For what purpose will the information be used?

* must provide value

In what form will the final product be disseminated?

Please describe in detail the data being requested (e.g., prevalence, incidence, specific variables, HIV infection, HIV-nonAIDs, Stage 3 AIDS, chlamydia, gonorrhea, syphilis - by stage).

* must provide value

In what format should the information be provided (e.g., electronic pdf)?

Geographic Area(s) of Interest

Statewide

By Public Health Districts

Other

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If other, please explain:

Time Period - Begin Date

* must provide value

M-D-Y

Time Period- End Date

* must provide value

M-D-Y

Data Stratified By

Race

Ethnicity

Gender

Public Health District(s)

Age

Other

If other, please explain:

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

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All publications utilizing the information must acknowledge the Alabama Department of Public Health (ADPH), HIV Surveillance Branch as the original source.
All interpretations and/or conclusions derived from the information provided must include a disclaimer crediting interpretation and/or conclusion reached to the authors and not to the ADPH HIV Surveillance Branch.
Parties must assure that technical descriptions of the data are consistent with those provided by the HIV Surveillance Branch.
The data provided must not be used for purposes other than those stated in the Data Request form without prior written approval from the HIV Surveillance Branch.
The data provided may not be released to any third party.
A copy of any material derived from the information requested will be sent to:

HIV:
Olubukola Alonge MD, MPH
HIV Surveillance Coordinator
201 Monroe Street, Suite 1291
Montgomery, AL 36104

STD:

Anthony Merriweather, M.S.P.H.
Director, Division of STD Director
201 Monroe Street, Suite 1440
Montgomery, AL 36104

7. Consultation with the Coordinator of HIV/AIDS Surveillance at (334) 206-6409 and with the Director of the Division of STD at (334)206-2765 to discuss uses and limitations of the data is encouraged.
8. The terms of this agreement extend to all employees, volunteers, interns and contractors of the signing entity.

By the signature below, I agree to abide by the terms and conditions provided above.

* must provide value

Add signature

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	______,______,______
Preferred Completion Date	______

Completed by Staff on:

M-D-Y

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