First Name*

Last Name*

Title/Credential/Degree*

Email*

Confirm Email*

Phone Number*

Organization*

Organization Website URL*

Length of time with the organization*

Supervisor Email*

Please list any additional collaborators you may be working with related to this data request.

1. Please select the ECIDS data sources that you are interested in*:
All Programs with Available Data DHHS Office of Early Childhood - ASQ Online DHHS Office of Early Childhood - Baby Watch Early Intervention Program DWS Office of Child Care - Child Care Subsidy Head Start - Centro de la Familia DHHS Office of Early Childhood - Home Visiting Program Legacy Data DHHS Office of Early Childhood - Home Visiting Program DHHS Office of Vital Statistics Birth Registry DHHS Office of Vital Statistics Death Registry DHHS Utah Women, Infants, and Children (WIC) Program

2. What type of ECIDS data are you interested in (See a list of available reports here)?*
ECIDS REPORT #1: CHILDREN UNDER SIX DATA SUMMARY REPORT ECIDS REPORT #2: ENROLLMENT DATA SUMMARY REPORT ECIDS REPORT #3: PROGRAM CROSSOVER DATA SUMMARY REPORT ECIDS REPORT #4: PROGRAM SEQUENCE DATA SUMMARY REPORT ASQ Screening Reports Other

3. What timeframes of ECIDS data are you interested in (See data availability for programs here)?*

4. Which regions(zip codes or counties) of Utah are you interested in, or statewide?*

5. Please describe how you intend on using ECIDS data.*

6. Please describe the audience for your intended ECIDS data use.

7. Please describe the format and method(s) for your ECIDS data sharing.

8. How long do you need access to ECIDS data for?

9. How frequently do you intend to analyze and/or share ECIDS data?
One Time Ongoing Quarterly Bi-annually Annually

10. If applicable, what type of analysis do you intend to do?

11. If you know your research questions and/or hypothesis please describe that here.