The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

DDP REDCap Report Request Form

To request data from the Division of Disease Prevention REDCap Data System, please complete the following form in its entirety. Please allow up to three weeks for all data requests at this time. If you have questions about your data request, please email DDPREDCap@vdh.virginia.gov.

Please note, this survey is to request data from the Division of Disease Prevention and is not associated with COVID19. If you need to submit a COVID19 complaint, please go to the COVID19 Complaint Form.

Thank you!

Name of Requester:

* must provide value

Requester Email Address:

* must provide value

Requester Phone Number:

* must provide value

Agency Name

* must provide value

Other Agency Name

* must provide value

Date of Request:

* must provide value

M-D-Y

Date needed by:

* must provide value

M-D-Y

The due date entered is less than 3 weeks after the request submit date. VDH will make every effort to provide your request in the time frame entered, however we may not be able to get your request to you in this timeframe.

Please enter a later date above, or mark 'yes' to acknowledge this possible delay.

* must provide value

Yes

reset

Reporting Period Start Date

* must provide value

M-D-Y

Reporting Period End Date

* must provide value

M-D-Y

What data are needed? (Select all that apply.)

* must provide value

Services and Demographic Summary Report

Client Line List

Other, please specify.

Other Data Needed

For summary reports, check all elements needed:

* must provide value

Services

Gender

Race

Ethnicity

Age

Income

Other, please specify.

Other data elements for summary reports:

For client line lists, please select all data elements needed:

* must provide value

First Name

Last Name

Date of Birth

Ryan White ID

Gender

Race

Ethnicity

Age

Income

Other, please specify.

Other Data Elements Needed for Client Line List:

Funding Source (Select all that apply.)

* must provide value

All funding sources

Part B only

MAI Part B only

Prevention for Positives

CHARLI

Other, please specify.

Funding Source Other:

Additional Comments

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