BRFSS Data Use Request Form

BRFSS Data Use Request Form

INSTRUCTIONS

Please read the Data Confidentiality Rules then complete the form. Your signature on this form certifies that you will comply with the data confidentiality rules and that you will ensure any other data users on your team will also comply with the confidentiality rules.

Data requests requiring significant processing may be subject to a fee to recoup personnel time and expenses. You will be notified in advance of any fees that must be paid prior to processing the request.

Please email BRFSS.Ask@odhsoha.oregon.gov with questions.

CONTACT INFORMATION FOR DATA REQUEST

Today's date*

Contact Name*

Email*

Phone*

Organization*

Street Address*

City*

State*

Zip*

Are you requesting ACES data?*

Would you like to hear from a staff member from Maternal and Child health to provide technical assistance for analyzing ACES data?

Yes

Select the dataset(s) you are requesting

BRFSS

Annual files are available for state and regional estimates, excluding county and zip code variables.

Combined year files are for county estimates.

Which files are you requesting?

Select

If requesting a dataset, what format would you like the file in?*

Select

GOALS OF DATA USE

Study Start Date*

Study End Date*

For what main purpose will you use the requested BRFSS data?*

(e.g., regional needs assessment, journal article, community report)

Which variables are you mainly interested in?*

(e.g., chronic health outcomes in eastern Oregon, family planning among women ages 25-40; exercise among people with disabilities)

Study Description*

Please describe any relevant details of your study. You can also attach documents below.

As Principal Investigator or Primary Data User, I certify that I have read and will comply with the data confidentiality rules*

Data Confidentiality Rules

As Principal Investigator or Primary Data User, I certify that I will ensure all data users on my team and under my supervision will comply with the data confidentiality rules*

As Principal Investigator or Primary Data User, I certify that a copy or abstract of any manuscript, report, brief, or other product prepared for public consumption and resulting from the use of these data will be communicated to the BRFSS program by email at BRFSS.Ask@odhsoha.oregon.gov*

I understand that I can get technical assistance or ask questions about the data by emailing BRFSS.Ask@odhsoha.oregon.gov*

Typing my name and email below serves as my signature and certifies my agreement with the above.

Name*

Title*

Email*

Include any supporting documents if applicable. (e.g., IRB, Study description)

Please add your program name to the end of the file name and upload the document.

Drag and drop files here or

Contact

Program Design and Evaluation Services

800 NE Oregon Street, Suite 260

Portland, OR 97232

Email: BRFSS.Ask@odhsoha.oregon.gov

Fax: 971-673-0590

Send me a copy of my responses

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