HIV/AIDS Surveillance Data Request Form

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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.

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* Purpose for Request:

Enter purpose for request here.

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

mm/dd/yyyy

to

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):

Enter cross tabulation information here.

Special Requests (please describe):

Enter special request information here.

 

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

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