Community Health Survey Data Request Form

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* 1. Requestor Information

Name

Organization

City/Town

Email Address

Phone Number

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* 2. When do you need this data by? Please note we would appreciate at least 2 weeks to fulfill requests. We may be able to fill requests sooner depending on staff availability and capacity.

Desired Data Delivery Date

Date

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* 3. Please describe the background and purpose of the proposed data request:

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* 4. Is this analysis for public release or program planning? Please describe the intended audience and who will view the results.

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* 5. Survey Years Requested

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* 6. What topics or questions are your interested in? Please list specific questions if possible. If you need more information about the type of data available, please contact Sue Hewitt at shewitt@healthdistrict.org or 970-530-2750

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* 7. What sub-groups are you interested in (if any)? Please include any specifics (i.e. specific age ranges, etc) in the comment box.

Age

Gender

Race/Ethnicity

Income

Education

Geography (Fort Collins, Loveland, etc)

Comments or Specifications:

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* 8. Acknowledgement of Data Ownership

By checking this box, I acknowledge that the data owner is the Health District of Northern Larimer County and that you agree to cite the source as the Health District of Northern Larimer County’s Larimer County Community Health Survey in any publication or other public use of this data.

Please include your name and date: