Section of Women's, Children's, and Family Health Data Request Form and Data Use Agreement Survey

Data Request Form

This form collects information about the data you are requesting and your planned research project. It is intended to be used by people requesting a dataset to analyze, not for summary data requests.

For group projects, only the primary applicant needs to complete the Data Request page. To sign the Data Use Agreement only, go to next page.

If you have questions about this form, email mch-epi@alaska.gov PRIOR to submitting so you will still be able to make updates if needed.

Revised May 2026

1.Project Title:

2.Anticipated end date (Month/Year):

3.Short Description and Purpose of Project:

4.Type of Data Requested

De-identified dataset

Limited dataset

Other (please specify)

5.Years and Variables Requested

Attach a list that describes years of data requested, variables of interest, and any other specific information we may need that describes the data you are requesting. If a limited dataset or one that includes other identifiers is being requested, explicitly state which identifying variables are being requested and the reason for the request.

No file chosen

6.Study Protocol (Optional, however the WCFH Program Manager may contact you to request this after receiving your request if we feel it is needed)

Attach a full study protocol following the MCH Epidemiology Data Sharing Protocol Outline. A full IRB proposal is sufficient to meet this requirement.

No file chosen

7.IRB approval (required for all non de-identified dataset requests)

Attach a copy of the IRB approval or letter of exemption. If no IRB approval for this project will be sought, explain in the Study Description.

No file chosen

8.Primary Applicant (person receiving data transfer)

Name

Agency

Phone Number

Email address

A signed Data Use Agreement must be received prior to release of data. See next page.