Form CDPH9046 "Std Data Request" - California

What Is Form CDPH9046?

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 December 1, 2017;
  • 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 CDPH9046 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 CDPH9046 "Std Data Request" - California

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State of California-Health and Human Services Agency
California Department of Public Health
STD Control Branch
Surveillance, Epidemiology, Assessment and Evaluation Section
STD DATA REQUEST
Requester: Please type or print. Sign and date on page 2.
Name:
Title:
Organization:
Mailing Address:
Email Address:
Phone Number:
Fax Number:
Date Requested:
Desired Completion Date:
Please allow a minimum of 10 working days for completion
Describe why you need California STD data and what question(s) you hope to answer? Who is your audience?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
DATA STRATIFICATION – Please specify desired strata
Disease(s)
Chlamydia
Gonorrhea
Syphilis:
Primary & Secondary
Early Latent
Late
Congenital
Other _______________________________ _
Geographic Areas
Statewide
Counties – all
Counties – selected __________________________________________ _
Other___________________________________________________________________________________ _
Demographics
Gender
_______________________________
Race/Ethnicity _____________________________ _
Age Group(s) ___________________________
Other ____________________________________ _
Time period requested
Start Year ______
End Year ______
Data by individual year, or
Years aggregated
(Calendar Years)
ANALYTICS
Case Counts
Case Rates
Other ______________________________________________________________________
FORMAT
DISPLAY:
Table
Graph
Map
Other ______________________________
OUTPUT:
Excel
CSV
SAS
PowerPoint
Other ______________________________
CDPH 9046 (12/17)
1
State of California-Health and Human Services Agency
California Department of Public Health
STD Control Branch
Surveillance, Epidemiology, Assessment and Evaluation Section
STD DATA REQUEST
Requester: Please type or print. Sign and date on page 2.
Name:
Title:
Organization:
Mailing Address:
Email Address:
Phone Number:
Fax Number:
Date Requested:
Desired Completion Date:
Please allow a minimum of 10 working days for completion
Describe why you need California STD data and what question(s) you hope to answer? Who is your audience?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
DATA STRATIFICATION – Please specify desired strata
Disease(s)
Chlamydia
Gonorrhea
Syphilis:
Primary & Secondary
Early Latent
Late
Congenital
Other _______________________________ _
Geographic Areas
Statewide
Counties – all
Counties – selected __________________________________________ _
Other___________________________________________________________________________________ _
Demographics
Gender
_______________________________
Race/Ethnicity _____________________________ _
Age Group(s) ___________________________
Other ____________________________________ _
Time period requested
Start Year ______
End Year ______
Data by individual year, or
Years aggregated
(Calendar Years)
ANALYTICS
Case Counts
Case Rates
Other ______________________________________________________________________
FORMAT
DISPLAY:
Table
Graph
Map
Other ______________________________
OUTPUT:
Excel
CSV
SAS
PowerPoint
Other ______________________________
CDPH 9046 (12/17)
1
State of California-Health and Human Services Agency
California Department of Public Health
STD Control Branch
Surveillance, Epidemiology, Assessment and Evaluation Section
STD DATA REQUEST
NOTES/Special Instructions
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
By submitting this data request I agree to the following provisions:
1. Protecting the confidentiality of surveillance information is our foremost concern. The release of surveillance data containing
individually identifying information is strictly prohibited. The terms and conditions for the release of data must be consistent with
applicable laws.
2. We reserve the right to suppress data to maintain case confidentiality. Data tables will not contain potentially identifying information,
small cell values, or information on small population subgroups.
3. All publications using the data provided must acknowledge this program. The following is a suggested citation: California Department
of Public Health, STD Control Branch, Surveillance, Epidemiology, Assessment and Evaluation Section. Provisional STD infectious data
provided per data request <date>.
4. The dissemination of any interpretation or findings based upon the data provided must be accompanied by the following disclaimer: The
authorized release of STD data by the California Department of Public Health, STD Control Branch, Surveillance, Epidemiology,
Assessment and Evaluation Section should not be construed as an endorsement of any analyses, interpretation, or conclusions reached
by the author(s).
5. The data provided will be used only for the purposes stated in the data requested form.
6. The data are provisional. Local Health Jurisdictions can modify or delete past case reports at any time, even months or years after they
hare initially reported due to the dynamic nature of the reporting surveillance system.
7. Data should not be released to a third party who is not listed on the request form. The third party should be referred directly to
California Department of Public health, STD Control Branch, Surveillance, Epidemiology, Assessment and Evaluation Section.
8. Research proposals involving human subjects may require approval of the California Health and Human Services Agency, Committee for
the Protection of Human Subjects, 400 R Street, Suite 359, Sacramento, CA 95811.6213, telephone (916) 326 – 3660, or consult the
CaLPROTECTS
website: https://cphs.keyusa.net/
9. Requesters agree not to use de-identified data to determine the identity of individual persons. Attempt to do so from public data is a
violation of the Federal Privacy Act, 5U.S.C. and the HIPAA Rule.
Signature
Type or Print name
Date
Completed form can be scanned and emailed to
stdepi@cdph.ca.gov
California Department of Public Health
STD Control Branch
850 Marina Bay Parkway
Building P, 2
Floor
nd
Richmond, CA. 94804-6403
Phone (510) 620–3400
Data: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/STD-Data.aspx
PRIVACY STATEMENT (CA CIVIL CODE SECTION 1798.17) THE INFORMATION COLLECTED ON THIS FORM IS USED TO PROCESS YOUR REQUEST FOR INFECTIOUS DISEASES BRANCH SURVEILLANCE
DATA.THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND ON FILE AT THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, INFECTIOUS DISEASES BRANCH. ALL INFORMATION REQUESTED ON
THE FORM IS REQUIRED IN ORDER TO PROCESS YOUR REQUEST, AND NOT SUPPLYING THE INFORMATION MAY CAUSE A DELAY IN THE PROCESSING OF YOUR REQUEST, ORDENIAL OF YOUR
REQUEST. ANY INFORMATION PROVIDED MAYBE DISCLOSED TO THE CALIFORNIA STATE AUDITOR, THE CALIFORNIA OFFICE OF HEALTH INFORMATION INTEGRITY, THE CALIFORNIA OFFICE OF
INFORMATION SECURITY AND PRIVACY PROTECTION, OR TO OTHER STATE AND FEDERAL AGENCIES AS REQUIRED BY LAW. INFORMATION: CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, OFFICE
OF LEGAL SERVICES, PRIVACY OFFICE, MS 0506, P.O. BOX 997377, SACRAMENTO, CALIFORNIA YOU HAVE THE RIGHT TO REVIEW THE RECORDS WE KEEP ABOUT YOU DURING NORMAL BUSINESS
HOURS. THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH PRIVACY OFFICE WILL, UPON REQUEST, INFORM YOU REGARDING THE LOCATION OF YOUR RECORDS AND THE CATEGORIES OF ANY
PERSONS WHO USE THE INFORMATION IN THOSE RECORDS. FOR MORE INFORMATION, CONTACT THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, PRIVACY OFFICE, USING THE FOLLOWING
CONTACT 95899-7377 OR PHONE 1-877-421-9634 OR BY E-MAIL AT:
Privacy@cdph.ca.gov
CDPH 9046 (12/17)
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