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Data Request Form

Department of Behavioral & Community Health

 

 

Dutchess County Department of Behavioral & Community Health
Data Request Form


* indicates Required Field

Name: *

Organization / Department: 

Street Address: 

City / Town / Village:   State:    Zip Code: 

Telephone: *  Fax: 

Email: *

Date of Request: *

The following information is to assist our Biostatisticians in completing your request.

  1. What is the purpose of your request? Please check appropriate box and then explain.*
    Research
    Grant Writing
    School Project
    Other


  2. What variables do you need (e.g. births, deaths)?*


  3. What time period are the data for (e.g. most recent year, multiple years, sequential/aggregate)?*


  4. Define your population:*
    1. Do you wish to restrict the data to certain age(s), race/ethnicity group(s), gender, or other characteristic, if available?:
      Age:
      All
      Specify Range(s):


      Race/Ethnicity:
      All
      Specify Group(s):


      Gender:
      Female
      Male
      Both
      Other:


    2. Do you wish the data to be displayed by any of the following population characteristics, if available?
      Age
      Race/Ethnicity
      Gender
      Other:


  5. For which geographic area(s) do you wish to have the data summarized, if data are available?*
    New York State
    New York State Including New York City
    New York State Excluding New York City
    Dutchess
    Other(s):


    Dutchess County Municipalities:
    All
    Specify:


    Dutchess County Zip Codes:
    All
    Specify:


  6. What format do you need the variables in (e.g., numbers, percentages)?*

 

 

Please allow up to two weeks for processing of your request. Also note that individually identifiable health information is protected under the Health Information Procurement Accountability Act (HIPAA) and cannot be released.

 

Office Use:
Received by: _________________________________ Date received: _______________
Reviewed with: _________________________________ Date reviewed: _______________
Approved by: _________________________________ Date: _______________
Completed by: _________________________________ Date Completed: _______________

Dutchess County Department of Behavioral & Community Health – 85 Civic Center Plaza - Suite 106, Poughkeepsie, NY 12601 Fax: 845-486-3561 Email: healthinfo@co.dutchess.ny.us

Comments

 


 

*Enter the following number in the box below before submitting your Data Request Form*
   

 

  

 

A. K. Vaidian, MD, MPH,Commissioner of Behavioral & Community Health A. K. Vaidian, MD, MPH
Commissioner of Behavioral & Community Health
Dutchess County Seal

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