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Health Statistics Data Request Form
DOH FORM #HD01482F

E-Mail Address*

First Name*

Last Name*

Phone Number* ###-###-####

What specific data or technical assistance do you need?  Please be as specific as possible (e.g. - number and age-adjusted rate for accidental deaths by county for 2006 and 2007.)

Why do you need the data or assistance and how will you be using the data? (e.g. – I am a student working on a research project concerning cancer in Luzerne County.)