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* 1. Requester’s Info

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* 3. Intended Use (please provide a brief description of why the requested data are needed and how the data will be used to benefit public health)

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* 4. Capacity of Data Request

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* 6. If yes, where will it be disseminated, presented, and published?  (Please note that you must receive permission before submitting for publication.  You must submit a draft of the publication to SARAH at least 30 days before the official publication day, which could be the date of the conference presentation, or article in the online/or print journal).

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* 7. Describe, in detail, the information you are requesting, including specific demographic variables (e.g., gender), the time-frame of data (e.g., October 1, 2018 to September 30, 2019), and variables of interest (e.g., number of occupied beds).

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* 8. Type of Calculations:

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* 10. Please sign and upload your signed-data use agreement here.

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