Data Request Form

Requestor Information:

Name:

Organization:

Address:

City:      State:      Zipcode:

Phone:

Fax:

Email:

Purpose of Request:

Data Requested:

(e.g. HSCRC Inpatient Data, Ambulatory Care Data, Vital Statistics, BRFSS , NVDRS)

Years of Data:

Geographical Area (jurisdiction):

Information Requested: 

(e.g. rates, numbers, age groups, ICD-9/ICD-10 codes, etc)

3. Maryland BRFSS State of the State Report 2002 Survey Results on Maryland Healthy Behaviors and Lifestyles (please refer to ‘BRFSS 1993-2002 Questionnaires, Manuals and Yearly Reports’ under ‘Survey Tools’)

  

Only submit this data request form if the BRFSS data required are not available from the Maryland BRFSS website.