Infectious Epidemiology Form

REQUEST FOR DATA FORM

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

The information will assist DDC to prepare and develop useful statistical reports and provides aditional resources to external stakeholders and facilitates timely processing of all requests for public health surveillance information.

If you have any questions, please do not hesitate to contact Barbara Brazier at (207) 287-5301 or at 1-800-821-5821.

Individual and Organization Requestor Information

1. Contact Person (person requesting data)

Name
Title
Organization
Address
Email Address
Telephone
Fax
2. Overall Responsible Party
Name
Telephone
Fax
Date Request Made
Date Info Needed
Description of Requested Analysis 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 areas, 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 happened 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 pls 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.