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Service or Material Request Form

This request can be submitted by clicking on the Submit button at the bottom of the form.

* Indicates required information.

Requestor Information
* Date Submitted  (mm/dd/yyyy)  * Date Needed (mm/dd/yyyy)
*Name
  Title
*Address
*City   *State  *Zip
  Phone     Ext      Fax
*Email


Service or Material Requested (check off what is needed)

     HSEES Public Use Dataset (to do your own data analysis)

Please mail me a CD
I will download from this website
     Custom Data Request (describe exactly what data is needed) 
           

     HSEES Brochure (number of copies)
      HSEES Report Year(s) Number of Copies
     HSEES Protocol
     HSEES Data Collection Form and Training Manual
     Journal Article:
           Lead Author 
                       Year     
           Title or Topic
     Clearance of HSEES related materials that will be disseminated
     Other (specify)
          



Information Dissemination Will this information be disseminated in any way (i.e. as part of a fact sheet, report, presentation,
poster, journal article)
Yes, redistributed as is
Yes, as part of something new
No

PLEASE COMPLETE ALL OF THE INFORMATION SO THAT WE MAY CONTINUE TO JUSTIFY THIS PROGRAM AND PROVIDE THESE SERVICES

*Target Audience Type(s)
      (i.e. EMS, Industry Saftey Personnel)

*Approximate Audience Number
   (i.e. copies distributed, attendees at the conference, or hits on website)

Intended purpose for requested materials (check off all appropriate)
Internet site URL or name:
Fact Sheet topic:
Report topic: 
Journal article topic:
    submitting to:
Newsletter topic: 
    submitting to:
Poster or presentation for
a conference, meeting etc		 topic:

    Conference Name:

    Date (mm/dd/yyyy):
General awareness information on the program  
       
Other (specify)  

Is this an HSEES approved prevention outreach activity   Yes   No

If not submitting online, submit to HSEES, ATSDR/DHS/SRB, 4770 Buford Highway, Mailstop F-57,
Atlanta, GA 30341, Fax to 770-488-1537, E-mail ARAnderson@cdc.gov

_________________For Official Use Only_________________

ID#___________Date Received__/__/____Date Completed__/__/____Initials____


* Please check before submission for security reasons.
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