LTDHD Data Request

For questions please email elizabeth.tennison@ltdhd.org. For a records request, visit the record request forms section of the website.

1. Name *This question is required.

2. Organization or LTDHD Department Name *This question is required.

3. Email Address *This question is required. This question requires a valid email address.

4. Phone Number *This question is required.

5. If you are an LTDHD Employee, data must meet the following criteria: (Please check all that apply)

Align with Community Health Improvement Plan strategies
Evidence based program implementation or evaluation
Data requested for community stakeholders to impact policy, environmental, or systems change
Not applicable

6. If you are not an employee, please choose one of the following:

Please enter an 'other' value for this selection.

7. Reason for request and how the information will be used (How will the data be shared? Who is the intended audience?):

8. The specific data being requested:

9. Requesting counts or rates (e.g. the number of occurrences, mortality rates):

10. Time Period (10 Year Maximum):

11. Lincoln Trail District Geographic Area (County, Zip Code [if available]). State and U.S. for comparison [if available]:

12. Data Aggregated by (race, gender, age [if available]):

13. Requested date of completion:

14. Format of product desired (Excel, Word, Infographic, PowerPoint, etc.):

15. If you have a sample, please submit as an attachment with this request.

File: {{filename}} delete

16.

Requests will be reviewed by the Health Impacts Administrator. Completion will be as close to the due date as possible. Please allow up to 5 business days for a reply. By receiving data from the Lincoln Trail District Health Department (LTDHD), I agree to the following:

I will let LTDHD review any document that uses the provided data before publishing.
I will cite LTDHD or source(s) provided for all studies and applications while using the provided data.
I agree to protect and hold harmless LTDHD and its staff from any claims or liabilities arising from misrepresentation, unauthorized use, or disclosure of the data.
If given a raw data set, I will not share it with others without LTDHD's permission.

By checking this box, I agree to the above

17. Signature of Requestor *This question is required.

Clear

Signature of