Data Request

Nebraska Department of Health and Human Services Data Request Form

Exit Survey »

Name

Title

Organization

Address

Phone Number

Work for Nebraska Department of Health and Human Services?

Yes

Purpose of Data Request(what the data is required for):

Data Type

Aggregate Data

Record-based Data

Description of Data Required(Please include dates/time frames for any analysis, and other specific Categories and selection criteria required in the data)

What types of data format you prefer(Select all that apply)?

Customer (if not requestor)

To be used in (presentation, report etc) – please specify

Intended Audience (if appropriate)

Data Request Date

Desired Completion Date

Please keep in mind that the Office of Health Statistics takes its responsibility to protect the confidentiality of health data very seriously. We expect you to have sufficient security measures in place to assure us that no patient identifying information supplied to you by this office will be seen by any but the intended recipients. If any of this is unclear, or you have any questions about security and/or another aspect of the data request process, please feel free to call 402-471-2180.