PRAMS Data Request Form

    Today's Date

    Date Needed

    Requested By

    Your Name (required)

    Your Organization/Affiliation (required)

    Your Email (required)

    Your Telephone (required)

    Product

    Year(s) of data requested

    Please describe your project

    I understand that the data I receive can only be used for the purpose(s) indicated on the request form. Any other use should be approved by the Maternal and Infant Health Program.

    I agree that the data I receive cannot be published without written approval from the Maternal and Infant Health Program.

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    Privacy │ Terms

    This Utah Department of Health and Human Services web site is designed for informational and educational purposes only. The Maternal and Infant Health program does not see patients and is unable to diagnose your illness, provide treatment, prescribe medication, or refer you to specialists. If you need medical treatment, please see your health care provider.

    If you would like Maternal and Infant Health Program staff to contact you, please provide the information in this form. Without this information, we will be unable to assist you. Information is shared only internally with DHHS and, if necessary, with contractors who are part of the technical team that manages the account. Your data will not be sold. Record series 31351.