Form CDPH8719 "Request for Hiv Prevention Program Reports" - California

What Is Form CDPH8719?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2011;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8719 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8719 "Request for Hiv Prevention Program Reports" - California

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California Department of Public Health-
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State of California- Health and Human Services Agency
Office of AIDS
Request for HIV Prevention Program Reports
Please type or print information below.
Requestor Name:
Requestor Title:
Organization:
Telephone Number:
Fax Number:
E-mail Address:
Date of Request (mm/dd/yyyy):
Desired Date of Completion (mm/dd/yyyy):
Return this completed form to the California Department of Public Health, Office of AIDS at:
Leodatarequest@cdph.ca.gov
Note: Please allow at least two to four weeks for completion of data request.
1.) Purpose of Data Request (mark all that apply):
Program Planning/Evaluation
Grant/Proposal Application
Internal Health Department Use Only
Needs Assessment
Community Planning
Other, please specify:
2.) Geographic Area(s) Requested:
Statewide
County(ies)/Local Health Jurisdiction(s), specify:
3.) Program of Interest:
Counseling & Testing
Health Education/Risk Reduction
Partner Services
All Agencies
Specific Agency(ies):
4.)
All Interventions
Specific Intervention(s):
5.)
All Locations
Specific Location(s):
6.)
to
7.) Time Period of Interest (mm/dd/yyyy):
8.) Please Describe the Information You Are Requesting (Be specific. [e.g., test results by
race/ethnicity, positive clients linked to care by gender, number of encounters by
intervention]):
Continued on Back...
CDPH 8719 (7/11)
Page 1 of 2
California Department of Public Health-
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State of California- Health and Human Services Agency
Office of AIDS
Request for HIV Prevention Program Reports
Please type or print information below.
Requestor Name:
Requestor Title:
Organization:
Telephone Number:
Fax Number:
E-mail Address:
Date of Request (mm/dd/yyyy):
Desired Date of Completion (mm/dd/yyyy):
Return this completed form to the California Department of Public Health, Office of AIDS at:
Leodatarequest@cdph.ca.gov
Note: Please allow at least two to four weeks for completion of data request.
1.) Purpose of Data Request (mark all that apply):
Program Planning/Evaluation
Grant/Proposal Application
Internal Health Department Use Only
Needs Assessment
Community Planning
Other, please specify:
2.) Geographic Area(s) Requested:
Statewide
County(ies)/Local Health Jurisdiction(s), specify:
3.) Program of Interest:
Counseling & Testing
Health Education/Risk Reduction
Partner Services
All Agencies
Specific Agency(ies):
4.)
All Interventions
Specific Intervention(s):
5.)
All Locations
Specific Location(s):
6.)
to
7.) Time Period of Interest (mm/dd/yyyy):
8.) Please Describe the Information You Are Requesting (Be specific. [e.g., test results by
race/ethnicity, positive clients linked to care by gender, number of encounters by
intervention]):
Continued on Back...
CDPH 8719 (7/11)
Page 1 of 2
Additional Notes (If you would like the results grouped, please describe. [e.g., separate by agency,
intervention, intervention type, type of test, location]):
By submitting this data request I agree to the following provisions:
1.) Data sets are updated monthly. For the most current data, please request close to the beginning of
the month;
2.) The Office of AIDS reserves the right to suppress data to maintain confidentiality. Data report(s) will
not contain potentially identifying information, small cell values, or information on small population
subgroups;
3.) All publications using the report(s) provided must cite the Office of AIDS. The following is a
suggested citation: California Department of Public Health, Office of AIDS, Program Evaluation and
Research Section, Data Request, <date>;
4.) The dissemination of any interpretations or findings based upon the report(s) provided must be
accompanied by the following disclaimer: Authorized release of HIV Prevention Summary data by
the California Department of Public Health, Office of AIDS should not be construed as an
endorsement of any analyses, interpretations, or conclusions reached by the author(s); and
5.) The report(s) provided will be used only for the purposes stated in the data request form.
FOR OFFICE OF AIDS USE ONLY
Office of AIDS Request I.D. #:
Request Received by:
Date (mm/dd/yyyy):
Request Approved by Manager:
Date (mm/dd/yyyy):
Assigned to:
Date (mm/dd/yyyy):
Comments:
Work Reviewed by:
Date (mm/dd/yyyy):
Amount of Time Spent on Report:
Date Request Delivered (mm/dd/yyyy):
CDPH 8719 (7/11)
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