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Immunization Data Request Form

* Salutation

* Requesting Individual

* Name of Company/Organization

* Street Address

* City, State Zip Code

* Contact Phone Number

* Contact Email Address

* Project Title

* Purpose of the Data
Describe how data will be used for the purpose of making suggestions and ensuring proper information is gathered.

* Description of Request
Please provide a brief description of the request. Be sure to specify (1) the population or group of interest and (2) the specific fields needed for viewing.

* Timeframe of Data Requested
Beginning date of data to be collected.

* Timeframe of Data Requested
End date of data to be collected.

* Geographic area to be included in data
Choose State or Specific Counties in Alabama

Use Shift or Ctrl keys to select multiple values.

* Date Information Needed By
Please give us at least 7-14 business days to process your request.

* What is the anticipated frequency of this request?

Other (Please specify):

* Preferred format?

Other (Please specify):

* Is this request similar or same as a previous request?
If the answer is no, please skip the next question.

What is the name of the previous request and when was it received?
If answer was no to the previous question, please skip to the next question.

Please provide any additional information about this request.

Please email any attachments that may be helpful to Include the "Project Title" in the subject line.