Common Contracts
1 similar Data Request Agreement contracts
DATA REQUEST FORMData Request Agreement • January 24th, 2013
Requester name Organization Program E-mail address Mailing address (number and street) City, state and zip code Telephone number Fax number Date of request Desired completion date Detailed description of data request: (Please be as specific as possible, e.g. demographics, years, location, etc.) What question(s) do you need answered? What year(s) do you need information for? What is the purpose of the data requested?Who is your audience? What delivery format do you need? □ Paper □ Electronic (email) □ Other: Provisions of this agreement: All documents, presentations, etc. that use the information provided must cite the Epidemiology Program, San Joaquin County Public Health Services, as the source. Use the data provided only for the purposes stated in the data request form and do not release it to any third party, unless you obtain prior written approval from the Epidemiology Program. Any conclusions or interpretations reached by the requester and not by the Epidemi
