ADHS Data Request Submission Form

ADHS Data Request Submission Form

*Please Do Not submit any Personal Identifiable Information (PII) or Protected Health Information (PHI) in your request.

The intention of this form is to aid in the process of efficiently routing data requests to the appropriate data owners within ADHS

Kindly give ADHS at least 10 business days to respond to your request. Someone may reach out to you for more information. If you don't hear back within 10 business days, please submit a Follow-Up request and include the Data Request ID you received with your initial submission.

Disclaimer - Fulfillment of data requests are at the discretion of ADHS data owners as they consider factors such as confidentiality, feasibility, and allowable purposes of the public health data. This webpage and the material contained herein are provided as a public service for informational purposes only. It should not be considered legal advice or opinion, and, unless expressly noted it does not reflect official ADHS policy.

Please visit the ADHS Data Requests website for additional information about this form or data requests.

Welcome to the Data Request Submission Form

First, please look for the data you need in our Public Health Data Portal, which contains all publicly available ADHS datasets.

If you do not find the data you need there, then please complete this form to submit a request for a curated dataset.

Are you submitting a new data request or following up on a previously submitted request?*

Select

Please provide a summary of your prior request including the Data Request ID you received after submitting this form initially.*

Thank you for visiting the ADHS Data Request Site.

Please Provide your Contact Information

First Name*

Last Name*

Email Address*

Confirm Email Address*

Phone Number*

Job Title (Enter N/A if not applicable)*

Organization (Enter N/A if not applicable)*

Are you requesting this data on behalf of someone*

Select

Details of request on behalf of others

What best applies to you?*

Select

You identified your request as AZ Intrastate Agency or Non-AZ Government Agency. Are you requesting data for one of the following: Rules/Statutes/Executive Orders/etc.?*

Select

You identified your request as County Health Department. Are you looking to make changes to your existing Memorandum of Understanding/Data Sharing Agreement with ADHS?*

Select

County Name*

Select

You identified yourself as a Tribal Nation or Tribal Health Department. Are you looking to make changes to your existing Memorandum of Understanding/Data Sharing Agreement with ADHS?*

Select or enter value

Tribal Nation or Tribal Health Department Name*

You identified your request as Contracted by Public Health to Use PH Data, do you have an existing Data Sharing Agreement with ADHS?*

Select

You identified your request as Research/Student, are you requesting data for research through one of these universities: ASU or NAU or UA?*

Select

You identified your request as ADHS Staff, please select from the dropdown list the bureau/office which you would like this request to be forwarded to.*

Select

Do any of the following apply?*

Select

Do any of these additional categories apply?*

Select

Please enter the Rule/Statute/EO/Etc and pertinent Dataset being requested below and someone will reach out to you shortly.

If known, please enter the MOU/DSA number and details of any additional datasets you are requesting under the existing MOU/DSA and someone will reach out to you shortly.

Please enter a detailed description of your request below and someone will reach out to you.*

Do not include any identifying or health information about individuals (e.g., date of birth, address, etc.).

Please include detail in your description that will help us effectively route your request to the appropriate department and data owner (e.g., a list of the variables that you are wanting to be included, a description of the questions you are trying to answer with this data)

How will you use this data (Select all that apply)*

Select

If Other - Please Specify*

If you want this request or follow up routed to a specific contact at ADHS, in addition to our data management office, please enter their email here.

This form is part of an ongoing project to streamline data requests for the Arizona Department of Health Services. We are interested in your feedback regarding the form or future needs when requesting data.

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