Please complete this form when submitting a report/data request to the CPCA data team. In order to help expedite the request please provide as much detail as possible. Please complete all fields below. This form will be reviewed by the data team and will be in contact with you regarding the progress of your report. For questions, please email Takhmina Amin-Rahbar at trahbar@cpca.org. 

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* 1. Contact Information.  Please provide the following information so we can confirm your survey response.

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* 2. Please check type of Report/Data Requested

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* 3. Purpose for Data Request 

Please provide specific details on the objectives of your request. Include details on what level the data should be summarized:

(By Health Center, Health Center site, county, statewide, legislative district, congressional district, etc.)

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* 4. Reason for Data Request and for whom:  e.g. CHCF; legislator; member, etc.
 (important if requesting UDS proprietary data)

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* 5. Report Format:

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* 6. Other Comments:

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* 7. Data Staff assigned to request: CPCA to complete this portion

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* 8. Date Request Completed: CPCA to complete this portion

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