| 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 Infectious Disease Division is the lead program in the collection, analysis and interpretation of public health disease surveillance data, specifically, notifiable diseases and/or conditions. Requests for data from external stakeholders are ongoing and the Request for Data form repersents 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 enggage the requestor to consider the need and justification for requesting the data.
This information will assist I.D.D. to prepare and develop useful statistical reports and provides additional resources to external stakeholders and faciltiies timely processing of all requests for public health surveillance information. |
| Please complete the following: giving information that is as detailed as possible. The information you provide will serve as the criteria for the Infectious Disease Epidemiology Program to respond to your data request. After receiving your request, it will be reviewed for feasibility. You will be contacted with any questions or concerns. |
| 1. Please provide a title or brief description of the requested analysis. |
|
|
| 2. Time period for data requested: for what years are you requesting analysis or 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? |
| 3. Geographic area requested: what geographic area(s) are of interest (statewide, counties, one specific county, health service ares, city/town, etc.)? |
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. |
| 4. Data elements requested: describe as specifically as possible the information you would like to obtain. Be sure to indicate whether you are interested in an event that happend to Maine residents or are interested in events that occured in Maine. |
|
|
| 5. Provide any other details needed to complete your request. |
|
|
6. Format in which analysis should be sent:
Paper Report
Electronic file (spreadsheet)
Email
Other
Specify
|
| 7. Please indicate the way(s) in which the health information you requested will be used to benefit the population of Maine and/or public health. |
|
|
|
