Data Request Form

1. You are requesting from what unit (Data Owner)?

2. Email Address of the Data Owner.

3. Title of Your Request

4. Purpose of Your Request

5. Your Email Address

6. Your Name

7. Your Unit

8. Date Needed

9. List of Data Fields Requested Add the data fields you need and a brief description of each field.; Add Field

11. How are you going to protect the data from unauthorized access? (Security Measures)

12. Data Rentention

13. If you are disposing the data, what disposal method will you use?

14. Upload Supporting Documents (if any)