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Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

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Statewide Initiatives



211 - Get Connected. Get Answers.

Chronic Disease Data Request

Name:

(First Name)

(Last Name)
Request Date:
Organization/Institution:
Department:
Mailing Address:
City:
State:
Zip Code:
Telephone:

(xxx-xxx-xxxx)
Fax:

(xxx-xxx-xxxx)
E-Mail Address:

(Please make sure to double-check that your entry is correct.)
Is this organization/institution subject to the Freedom of Information Act or similar laws, which requires release of all information on request:
Choose one:
Yes
No
Brief Description of Requested Data Report:

(All reports will be delivered in pdf format.)

DESCRIPTION OF DATA REQUESTED
Diseases (Select all that apply):
Asthma
Cancer
Diabetes
Heart Disease/Stroke
Obesity
Oral Health
Tobacco
Other (Specify Below)
Diseases Other: Specify:
Inclusive Years From:

(Example: 1999)
Inclusive Years To:

(Example: 2012)
Gender:
Male
Female
Both
Age Range:
Adults (18+)
Other (Specify below)
Age Other: Specify:
Race (Select All that Apply):
White
Black or African American
AI/AN
Hispanic or Latino
NH/PI
Other (Specify Below)
Race Other: Specify:
Geographic Location (Select All that Apply):
State
Region
Parish
Regions (Select All that Apply):
All Regions
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Parishes (Select All that Apply):
All Parishes
Acadia
Allen
Ascension
Assumption
Avoyelles
Beauregard
Bienville
Bossier
Caddo
Calcasieu
Caldwell
Cameron
Catahoula
Claiborne
Concordia
DeSoto
East Baton Rouge
East Carroll
East Feliciana
Evangeline
Franklin
Grant
Iberia
Iberville
Jackson
Jefferson
Jefferson Davis
Lafayette
Lafourche
LaSalle
Lincoln
Livingston
Madison
Morehouse
Natchitoches
Orleans
Ouachita
Plaquemines
Pointe Coupee
Rapides
Red River
Richland
Sabine
St. Bernard
St. Charles
St. Helena
St. James
St. John
St. Landry
St. Martin
St. Mary
St. Tammany
Tangipahoa
Tensas
Terrebonne
Union
Vermilion
Vernon
Washington
Webster
West Baton Rouge
West Carroll
West Feliciana
Winn
Method of Transmission:
Requested Data Is Needed By:

Disclaimer: Data request will be based on the available data for the geographic area specified in the request. Please allow 5-10 business days to complete each data request. If additional time for data request is needed, due to the nature of the data request, you will be contacted to discuss an alternate delivery date.
I will abide by all confidentiality laws and regulations applicable to the Office of Public Health regarding Chronic Disease data provided.
Recipient's Name:
Date:
For more information related to this form or data requests, please contact:

Nkenge Jones-Jack, MPH
Chronic Disease Prevention and Control Unit
2020 Gravier St., 3rd Floor
New Orleans, LA 70112
Phone:504.568.5955
Fax: 504.568.5701
E-mail: njack@lsuhsc.edu