Internal Data Request Form

Internal Data Request Form

REQUESTER INFORMATION

Enter your first name*

Enter your last name*

Enter your email address*

Confirm your email address*

Enter a phone number in which you can be reached during business hours (Mon - Fri, 8 am - 5 pm EST)*

When do you need this request fulfilled by?

DCH has a standing service level agreement depending on the type and complexity of request. We will do our best to complete the request by this date, however providing this date does not guarantee delivery by this date.

REPORT INFORMATION

Title of Your Request*

Report Audience*

Select the option which best describes the audience for your data request.

I am requesting this data for internal DCH use.

I am requesting this data for the Governor’s Office or Legislature.

I am requesting this data for the Media/Press.

I am requesting this data for Other audiences.

How will data be used?*

Definitions: Health Care Operations - any of the following activities of the covered entity to the extent that the activities are related to covered functions. Research - systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge.

Health Care Operations

Legislative

Public Health

Research

What question/objective are you trying to answer?*

Please provide the question and objective you intend to answer with the requested data. Providing specificity on the intended use allows us to better meet your data request needs.

Sub-program*

Fee-For-Service (FFS)

Managed Care (CMO)

All

From Date*

To Date*

Note: Our data may lag by six to eight weeks of the current time period.

Date Column*

Please select one or more date options for your data request. Use the Additional Comments and Criteria section to provide details on how to use multiple selected date parameters. (Select all that apply)

Select

Report Format

Please select from the list below your preferred report format. Use the Additional Comments and Criteria section to provide details on how to use multiple selected Report Format parameters. (Select all that apply) The default option is "--No Preference--." If you do no select an option, DSS will provide a Report Format best suited for your request.

--No Preference--

Additional Comments/Criteria

• Use this field to indicate additional specifications for your data request. • Examples include listing data elements or defining population criteria. • Completion of this field is optional; however, specificity allows us to better meet your data request needs.

Supporting Documentation

Please attach any documents to support your data request. Examples include previously created reports, code listings, and report templates.

Drag and drop files here or

DISCLAIMER

By typing your full name in the box below, you agree to the following:*

• The name in the box below is the same person completing this data request form • The information requested will be used for the purpose stated in this request only • The information requested will not be used for malicious intent.

DCH Division

Select

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