MIEMSS Data/Analysis Request Form
*
Denotes required fields.
First Name
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Last Name
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Requesting Organization
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Department
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Street Address
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Address Continued
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
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Phone
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Email Address
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Please state the purpose of the request
*
Please specify the data time range (reporting period)
From:
To:
Other
(format: mm/dd/yyyy)
(format: mm/dd/yyyy)
When is the request data / Analysis needed?
Will these data or associated statistics/graphs etc. be published?
Yes
No