Request Form
	Please provide below as much information as possible to help us accurately direct your request.

	Request Form

	* Required
	Basic Information
	1. Contact First Name *
	This question is required
	2. Contact Last Name *
	This question is required
	3. Primary Contact Title  (ex: Director,Reporter,etc...)
	4. Phone
	5. Address
	6. Address 2
	7. City
	8. State
	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
	9. Zip
	10. Email Address *
	This question is required
	11. Are you a member of the media? *
	Yes No          This question is required
	12. Organization Name
	13. Type of Organization
	Select your answer Academic Academic and Healthcare Corporation or Business Government - Federal Government - Local Government - State Healthcare Individual Law Firm Media NGO Non-Profit Other
	14. Type of Request *
	Select your answer Data Request Public Records Request Other          This question is required

	* Required
	Data Request
	15. If provided,when will you need data delivered?
	16. Data Subject Matter            Select all that apply.
	COVID-19 Acute Care Systems Asthma Behavioral Risk Factor Surveillance System (BRFSS) Boilers and Pressure Vessels Breast or Cervical Cancer Child and Adolescent Health Chronic Disease Community Health CYSHCN Delta Health Collaborative Dental and Oral Health Early Intervention Emergency Medical Services (EMS) Emergency Planning and Response Entomology Environmental Lead Epidemiology Food Protectioin Genetic Services Healthy Moms, Healthy Babies (PHRM/ISS) HIV or AIDS Hospital Discharge Data System Immunization Infant Mortality Lead Screening Medical Records Milk or Bottled Water Opioids Perinatal Pharmacy PRAMS Preventive Health Primary Care Public Health Lab Radiological Health Radon Program Reportable Diseases Reproductive Health Rural Health Substance Use Disorders
	17. Description of data requested: *           Please provide clear description along with any applicable dates. Instructions for adding           attachments will be provided after submission or Attachments can be sent by email to           InfoRequests@msdh.ms.gov.
	This question is required
	18. Intended use of data requested: *
	This question is required
	19. Are you requesting protected health information (PHI)? *
	Yes No Do not know            This question is required
	20. Who inside and outside your organization will have access to the               data? *           Please provide names and work titles where possible.
	This question is required
	21. If provided, how would you like the data delivered? *
	Electronic Mail Pick Up Fax Other            This question is required
	22. Notify me if fee exceeds           NOTE: If a cost is applied, payment is required before records will be retrieved
	$10            $25            $50
	23. Extra Notes:

	* Required
	Public Records Request
	15. Records Requested *          Please indicate if you wish to only inspect the records, receive a copy, or inspect then copy.          Please provide clear description with dates. Instructions for adding attachments will be provided          after submission or Attachments can be sent by email to InfoRequests@msdh.ms.gov.
	This question is required
	16. Intended use of data requested:
	17. If provided, how would you like the data delivered? *
	Electronic Mail Pick Up Fax Other          This question is required
	18. Notify me if fee exceeds        NOTE: If a cost is applied, payment is required before records will be retrieved
	$10          $25          $50
	19. Extra Notes:

	* Required
	Other
	15. What information and/or service are you requesting from the agency? *
	This question is required
	16. Extra Notes: