Public Health: Initial Data Request
DPH Data Management and Governance
Contact Information
Who is making the data request
Who is making the data request?
*
An Organization
An Individual
A State of CT Agency or Office
A CT DPH Program/Unit
Organization Name
Name of the organization making the data request.
Enter the DPH Program/Unit Name
Select a State Agency/Office
Please Select
Administrative Services
Children and Families
Consumer Protection
Developmental Services
Economic & Community Development
Energy & Environmental Protection
Emergency Services & Public Protection
Mental Health & Addiction Services
Motor Vehicles
Agriculture
Banking
Correction
Housing
Insurance
Labor
Transportation
Public Health
Revenue Services
Social Services
Veterans Affairs
Early Childhood
Policy & Management
Education
Office of the Comptroller
CT Green Bank
Agricultural Experiment Station
Health Strategy
Aging and Disability Services
Office of Workforce Strategy
Office of the Treasurer
Only agencies/office with an Agency Data Officer are listed here.
Contact Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Reason for Initial Data Request
I'm requesting data from a single program or office and there is not a current data request process in place.
I'm requesting integrated data from across DPH programs or offices.
I'm requesting identifiable records for the purpose of integrating data from DPH with another data source
I need to discuss my data request with someone from the DPH Data Management and Governance Office
Data Request
Select which data sets you are requesting
Enter other data being requested here.
What type of data are you requesting?
Aggregate Data
Row Level Data
Integrated or Linked Row Level Data
Select the type of Aggregate Data you are requesting.
Aggregated data by specified subgroup/population/geography from a single dataset
Linked and aggregated data by a specified subgroup/population/geography from multiple datasets
Select the type of Row Level Data you are requesting.
Row Level data that has been deidentified
Row level data with direct identifiers (e.g. name, SSN)
Row level data with indirect identifiers (e.g. age, gender)
Underlying source data that has not been curated or manipulated
Select the type of Integrated or Linked Data you are requesting.
Type Row level data without identifiers linked with other DPH data performed within the DPH data infrastructure
Row level data with identifiers linked with other DPH data performed within the DPH data infrastructure
Row level data with identifiers linked with other DPH data performed outside the DPH data infrastructure
Row level data with identifiers linked with Non-DPH data performed within the DPH data infrastructure
Row level data with identifiers linked with Non-DPH data performed outside the DPH data infrastructure
What are the intended data uses?
Integrate with data internal to DPH
Integrate with data external to DPH
Analytics (public reports and dashboards)
Fulfill a legislative requirement
Administrative
Research
Fulfill a grant or cooperative agreement requirement
Other
Enter other data use here.
Will these data be shared with others?
Please Select
Data will not be shared with others
Data will be shared with others to fulfill the stated reasons with additional data sharing restricted.
Data sharing with others will not be restricted.
Only aggregate data will be shared with others
Unsure
Are there any planned third party releases?
Describe the primary reason for the data request
*
0/600
Describe the secondary reason for the data request
0/600
Data Request Date Range
Start and End Date of Request
Date Range: Start of Data Request
*
Date Range: End of Data Request
*
Upload of file containing the list of data elements being requested.
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What are the assumed legal authorities that support this data request?
Please enter any relevant State of CT, or Federal statutes and regulations.
What is the required refresh frequency for these data?
Please Select
One-Time provision of data
Daily
Weekly
Monthly
Quarterly
Annual
Other
Enter other refresh frequency here.
When are these data needed?
-
Month
-
Day
Year
Date
Why are the data needed by the requested date?
Please upload other supporting documents.
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of
Please verify that you are human
*
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Signature of Requestor
Signature
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