Data Request Form

If the data provided on this site does not meet your needs, additional information on Health Statistics in Mecklenburg County can be located on the website for the NC State Center for Health Statistics www.schs.state.nc.us/SCHS.

Request for Statistical and/or Epidemiologic Information

Before filling out this form, please consider data available on this site and what you need the data for.

Section I: General Information

Today's Date

Note: Please allow at least two weeks for fulfillment of data request

Date NeededNameName of Organization/AgencyType of Organization/AgencySpecify OtherAddressCityStateZipPhoneFaxEmailIs the data being requested for a grant?Yes
NoIf so, when is the grant due?
Section II: Data Request

Reason Requesting DataSpecify Other
Please describe in detail what data are needed.
Also include if data is needed by demographics (race/ethnicity, age, gender) and if you want trend data (by year). (Note: Please request only information needed. Data requests that are lengthy require more staff and will require more time than the allotted two weeks estimated to fulfill the data request.)

Please describe in detail what the data will be used for.

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