The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

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Required format:

Immunization Data Request

Please complete the form in its entirety to request population-level immunization data (eg: for epidemiological or public health reasons) from the Louisiana Department of Health.

Looking only for your own vaccination record? CLICK HERE!

Date of request

* must provide value

M-D-Y

Please verify: Are you requesting your OWN (or your child's) vaccination record for work, school or other purposes?

* must provide value

Yes

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}

To retrieve individual vaccination records, please visit: https://ldh.la.gov/page/request-vaccination-records.

NOTE: This form is only for requesting population-level data for epidemiology or public health purposes. It cannot be used to request individual vaccination records from the LA Immunization Program.

YOU MAY NOW EXIT THIS PAGE.

Name of requestor (first, last)

* must provide value

Organization

* must provide value

Phone number

Purpose: Why are you requesting these data?

* must provide value

Research

Media request

Program intelligence (for LDH internal use only)

External partner request

Other

If OTHER, please describe briefly.

Do you have approval from the LDH Institutional Review Board (IRB) for this research project?

* must provide value

Yes

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Please upload a PDF copy of LDH IRB approval.

* must provide value

Upload file

What is the scientific or program-related question you are trying to answer with these data? If you plan to do any statistical analysis, please provide a description of the independent and dependent variable(s) here.

* must provide value

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Do you need aggregated or record-level data? Please note there is no guarantee we will be able to provide even de-identified record-level data as we prioritize protecting patients' privacy. You will also require IRB approval before record-level data can be released.

* must provide value

Aggregated

Record-level

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Which are vaccine(s) are you interested in? Please list the vaccines's CVX codes and/or family codes. If you do not have the codes available, please list the names of the vaccines.

* must provide value

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What is the time period you need the data for? Please list all years/months for which you need the data.

* must provide value

What is/are the geographic level(s) you are interested in acquiring the data for? Please note that we may NOT be able to provide ZIP code and census tract level data if there are privacy concerns due to the number of patients or the size of the population.

* must provide value

State

Parish/County

LDH Administrative Region

Census Tract

ZIP code

Other

If OTHER, please describe.

* must provide value

Are there only SPECIFIC parishes (counties), regions, ZIP codes and/or census tracts you are seeking data for? (If you need data for all parishes/regions/etc. in Louisiana, instead of only specific ones, please select "No").

* must provide value

Yes

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If there are any SPECIFIC parishes (counties), LDH regions, ZIP codes and/or census tracts that you are requesting the data for, please list them ALL here.

* must provide value

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Do you need the data stratified by any of the following?

Sex

Age group

Race

Ethnicity

Please list your preferred age groupings here.

* must provide value

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Is there anything else you would like to share with us?

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Please upload any files (eg: results template, project description, details of the procedure/data request, etc.).

Upload file

What is your deadline for receiving these data?

Please note that we may not be able to honor your deadline given other priorities in the the queue and/or if unexpected issues arise during data processing. This is especially true if you need the data within <15 business days. However, we will do our best, and keep you informed of any changes to your preferred timeline.

* must provide value

M-D-Y

I understand that there is no guarantee that my data request will be fulfilled as requested if the program has concerns about how the data will be stored/used/reported, patient privacy protections, or for any other reason. I further understand that the data may need to be suppressed or aggregated as the program sees fit in order to protect patient privacy.

* must provide value

I understand

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.