OEPS Data Request
Sign in to Google to save your progress. Learn more
Email *
Your Name *
Phone Number *
How will this report be used? *
If you indicated Other, please explain. *
Report Type *
Level of Urgency *
Data Elements to be included on report:
 *
Required
If you indicated OTHER for the previous question, please explain.
                        PROGRAM AREA(S) AND DISEASE SPECIFIC CONDITIONS

From the following Program Areas select the specific condition for your data request.
Enteric Conditions (ENT) 
Select all that apply
Invasive Bacterial Diseases (IBD) 
Select all that apply
Multi-Drug Resistant Organisms (MDRO) 
Select all that apply
Respiratory Viruses (RV)
Select all that apply
Sexually Transmitted Diseases (STD)
Select all that apply
Tuberculosis (TB)
Select all that apply
Vaccine Preventable Diseases (VPD)
Select all that apply
Viral Hepatitis (HEP)
Select all that apply
Zoonotic Diseases (ZD)
Select all that apply
When is the data needed?  Please allow 30 business days, excluding holidays for response. More complicated data requests may require additional time. OEPS staff will reach out to communicate a feasible timeline after submission. 
 *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of State of West Virginia.

Does this form look suspicious? Report

Google Forms