Kent County Health Department
Data Request Form
Please allow a minimum of 5 working days to fulfill your request. Any requests that will need to be submitted to the
Michigan Department of Community Health may take longer than 5 days.
Date:____________________________________
Name:______________________________________________________________________
Address:____________________________________________________________________
_____________________________________________________________________
Daytime Phone Number:____________________________________
Fax Number:______________________________________________
e-mail:___________________________________________________
Instructor Name:_______________________________________________________________
Data Requested (please be specific)
Topic:_________________________________________________________________________
Data Year(s):____________________________________________________________________
Area/Region:____________________________________________________________________
Type of numbers/rates:____________________________________________________________
How would you prefer to receive the information? (please check):
Mail Phone Fax e-mail
Please mail or fax completed form to the Kent County Health Department:
Kent County Health Department
CD Epi Unit – Data Request
700 Fuller NE
Grand Rapids, MI 49503
Fax: (616) 336-4621
Completed by (KCHD use only):
