Data Request Form

  • The DDP Data Request Form is only for chlamydia, gonorrhea, syphilis, and HIV data requests. All other data requests should be made through the main VDH data portal.
  • Point of Contact

  • MM slash DD slash YYYY
  • Descripton of Data Request

  • HIV, gonorrhea, chlamydia, syphiliis
  • State, region, health district, county
  • Last five years, last calendar year, current calendar year, or other? Please specify and offer a beginning date and an end date.
  • Please be as specific as possible.
  • Table, chart, graph, etc.
  • MM slash DD slash YYYY
  • Purpose of Data Request

  • Additional Comments

  • This field is for validation purposes and should be left unchanged.