New Data Request

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Please complete this form in order to make a request for data from the Department of Health. Confirmation will be sent to the email address you provide.

OGC Email

Data Governance Email

Date Submitted

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Y-M-D

Submitter First Name:

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Submitter Last Name:

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Submitter Email:

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Submitter RACFID:

Submitter Division:

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Submitter Organization Name (if applicable):

What category best describes your organization?

Submitter Job Title/Role:

Submitter Phone:

Are you submitting this data request on behalf of someone you represent (the Data User)?

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Yes

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Data User First Name:

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Data User Last Name:

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Data User Email Address:

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Data User RACFID:

Data User Division:

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Data User Organization Name:

Full organization mailing address:

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What level of government do you represent or will you represent for the purpose of this request

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In what state do you reside?

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TN- I reside in the State of Tennessee

Other- I do not reside in the State of Tennessee

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For submitting a public records request, the department requires a copy of your government-issued identification or other evidence showing Tennessee residency. Tenn. Code Ann. §10-7-503(a)(7)(A)(vi).

If a request is made by a government agency, an official letter may be submitted for consideration by the department.

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Please specify the Federal Department/Agency on whose behalf you are acting.

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Please indicate the name of the State/Metropolitan agency on whose behalf you are acting. (For example: State of Tennessee Agency)

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Please indicate the name of the State/Metropolitan agency on whose behalf you are acting. (For example: State of Tennessee Agency)

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Do either of these options apply?

I am a professional member of the media

I seek data for research purposes

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