Department of Health & Hospitals

Name:

(First Name)

(Last Name)

Request Date:

Organization/Institution:

Department:

Mailing Address:

City:

State:

Zip Code:

Telephone:

(xxx-xxx-xxxx)

Fax:

(xxx-xxx-xxxx)

E-Mail Address:

(Please make sure to double-check that your entry is correct.)

Is this organization/institution subject to the Freedom of Information Act or similar laws, which requires release of all information on request:

Choose one:

Yes
No

Brief Description of Requested Data Report:

(All reports will be delivered in pdf format.)

DESCRIPTION OF DATA REQUESTED

Diseases (Select all that apply):

Asthma
Cancer
Diabetes
Heart Disease/Stroke
Obesity
Oral Health
Tobacco
Other (Specify Below)

Diseases Other: Specify:

Inclusive Years From:

(Example: 1999)

Inclusive Years To:

(Example: 2012)

Gender:

Male
Female
Both

Age Range:

Adults (18+)
Other (Specify below)

Age Other: Specify:

Race (Select All that Apply):

White
Black or African American
AI/AN
Hispanic or Latino
NH/PI
Other (Specify Below)

Race Other: Specify:

Geographic Location (Select All that Apply):

State
Region
Parish

Method of Transmission:

Requested Data Is Needed By:

Disclaimer: Data request will be based on the available data for the geographic area specified in the request. Please allow 5-10 business days to complete each data request. If additional time for data request is needed, due to the nature of the data request, you will be contacted to discuss an alternate delivery date.

I will abide by all confidentiality laws and regulations applicable to the Office of Public Health regarding Chronic Disease data provided.

Recipient's Name:

Date:

For more information related to this form or data requests, please contact:

Nkenge Jones-Jack, MPH
Chronic Disease Prevention and Control Unit
2020 Gravier St., 3rd Floor
New Orleans, LA 70112
Phone:504.568.5955
Fax: 504.568.5701
E-mail: njack@lsuhsc.edu

Louisiana Department of Health & Hospitals | Bruce Greenstein, Secretary

PCRH-Chronic Disease Data Request