Kansas Department of Health and Environment: HIV/AIDS Data Request Form

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HIV/AIDS Surveillance Data Request Form

HIV/AIDS Surveillance
Data Request Form

All data requests are completed in the order in which they are received. Please allow up to two weeks for processing. (In some cases, small cell size may inhibit the ability to report results as requested.)

* Denotes required fields.

* Submitted by:

* Organization:

* Phone Number:	* FAX Number:	* Email:
*** In order to submit a request for these records online a FAX number or email address is necessary.**

* Purpose for Request:

Time Period of Interest (if requesting prevalent data, only list the ending date):

mm/dd/yyyy

( * At least one selection is required for each section below for online submittal.)

HIV/AIDS Surveillance Definitions (.pdf)

* Date Selection Criteria:
Diagnosis Date
Reported Date

* Case Selection:
Newly Diagnosed Cases
Prevalent Cases
Cumulative Cases

* Geographic Area of Interest:
Statewide

Region # (see map below)
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9

* Diagnostic Category of Interest:
HIV Only
AIDS Only
HIV/AIDS Combined
HIV/AIDS Separated

* Demographic Categories of Interest:
Age
Gender
Race/Ethnicity
Risk Behavior

Cross Tabulation, if applicable (example: Age by Gender):

Special Requests (please describe):

* Output File Format:
PDF
RTF
HTML
OTHER (please specify):

HIV/AIDS Regional Map

Questions: Contact Andrea Hall at (785) 296-8701 or Fax: (785) 296-0792.

HIV/AIDS SurveillanceData Request Form

HIV/AIDS Surveillance
Data Request Form