HIV/AIDS Surveillance Data Request Form

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HIV/AIDS Surveillance
Data Request Form

Kansas HIV/AIDS Program

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.

* 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):


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

HIV/AIDS Surveillance Definitions (.pdf)

* Date Selection Criteria:

* Case Selection:

* Geographic Area of Interest:

 Region # (see map below)


* Diagnostic Category of Interest:

* Demographic Categories of Interest:


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

Special Requests (please describe):


* Output File Format:

HIV/AIDS Regional Map

Questions: Contact Arrie Morris at (785) 296-8701 or Fax: (785) 296-0792.