Gwinnett Coalition for Health and Human Services

Data Request Form

Organization Name:_________________________________ Date: ____________

Name of person requesting the data: _____________________________________

Address: ___________________________________________________

Phone: ___________________________

Fax: ___________________________

Email: ___________________________

Please provide as much detail as possible to the following questions:

Data being requested: _________________________________________

Preferred data format requested:_________________________________________

USE OF DATA:

o To further understand the operation of my organization.

o To enhance the understanding of individuals being studied for the purpose of improving their condition and/or the condition of the community.

Explain:

DISSEMINATION OF DATA:

What are your plans for disseminating the results or outputs of your analysis of this data?

(For Committee Use)

Action Taken by Committee: