Data Request Form


The TIIG team have designed this data request form to facilitate the ad-hoc data request process.  All individuals and organisations who would like to request data from the TIIG Injury Surveillance System should complete this form.

Please provide as much detail as possible, this will allow us to tailor the request to your needs and permit a prompt response (please see the data sheets which provide information on the fields collected at each A&E department).

Once this form has been submitted, we will contact you via email to let you know whether the data extraction is possible, and the timescale for completion. Any request will normally be carried out within one month of request verification.

Thank you for taking the time to complete this form.

Fields marked * are mandatory


Name:               * 
Organisation:     * 
Position:             * 
Address:             * 
Postcode:           * 
Phone Number: * 
E-Mail:               *   


Detailed description of data required: *


 


Reason for request/purpose of data: *


 


Source of data (please tick all that apply):








If other, please specify below:




Years:*

 


Age Groups (Please tick all that apply):







If other, please specify below:




Injury Group (e.g. Fall, Assault)




Area/Geography




Date desired by:*