Name
*
First Name
Last Name
Email address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization / company name
*
State
*
Type of data requested (select all that apply)
*
Medical Cannabis Program
Safe Driving Campaign
Other
Purpose of data request (select all that apply)
*
Research or peer-reviewed publication
Internal use for my agency/organization
External communication or presentation to stakeholders
Media article or press release
Student thesis or dissertation
Grant funding or application
Other
Description of your request and the purpose for which the data will be used
*
Please provide a brief description of your request and how you/your group plan to use the data including specific details on the objectives or abstract of your request, including indicators needed.
Define any required parameters or areas of interest
*
For example: race/ethnicity, sex/gender, age, years of interest, etc.
Request deadline
-
Month
-
Day
Year
Date the data is needed by
Preferred format of data
*
Raw data table (in rates, counts, percentages/frequencies, averages, and/or sums)
Chart or graph
Other
Preferred report format (select all that apply)
*
Excel (.xlsx)
Word (.docx)
PDF (.pdf)
Other
Describe how the data requested will be stored or protected by your agency or organization
*
Additional comments or questions
Submit
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