Data Request Form

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Revise the data request form to include detailed and relevant fields, such as contact information (e.g., email), and ensure alignment with request documentation requirements.

Data request

 Since the portal displays limited information based on the selected indicators, it should provide an opportunity for users to access more detailed information depending on request and permissibility of the data requested in accordance with the National Health Data Access and Sharing guideline. Users who require more information will fill out an online request form which is a slightly modified version of the manual request form which is part of the aforementioned guideline.  The assigned personnel of the Strategic Affairs Executive Office will provide an online response to the requester following internal approval processes. Below is the content of the request form.

1.       Date of request*: _________________________________

2.       Position of the requester: _________________________

3.       Requester*:

•          Individual (for private/personal purpose) 

•          Organization                        

•          Unit/Department within organization                          

1. Name of organization/Department/person requesting the Data/Information*: __________________________________________________

Requesting Organization	Requesting Person	Type of data requested:
MOH Agency  Health administrative unitHealth facilityResearch InstituteAcademic institution Implementing partnerDonorProfessional AssociationMedia Private/Consulting firmNGOInternational /Foreign OrganizationOther /specify/ ---------------------	Age _______________________________Sex: _______________________________Academic background:CertificateDiplomaDegreeOther (Specify): _________________Profession:ResearcherConsultantHealth Care WorkerUniversity/college studentJournalist/Media professionalPoliticianOther (Specify): ___________	Data setReport/Text documentAudioVideoGraphics/image /cartographyBiologic specimenFormat of data requestPrint/paper-basedElectronic (Digital) Biologic sample

9. Purpose data requested for*: _________________________________________________

10. The name of the dataset and year of undertaking________________________________

11.   Particulars/ Disaggregation of data requested

a.       Geographic (National, regional, zonal, Woreda, Kebele): _________________

b.       Age (Specify): _______________

c.       Sex (Specify): ________________

d.       Other demographic and socio-economic parameter/s: _____________

12. Consent*

I/we the undersigned solemnly agree that I/we use the data only for the purpose I/we requested for. I/we appropriately acknowledge the data owner/source that provided me/us access to this data in any publication or communication. I/we will not share the data to a third party without the consent of the data owner. I/we agree to be held accountable by any legal or administrative measures if I breach any of the above vows.

13. e-Signature*: ___________________________________ 

14. Contact address*

 Phone: _____________________________________ 

email: ____________________________________

Note: All the variables with asterisk (*) are mandatory fields.

7. Other functional requirements 

• Date of the update should be labeled in the dashboard

• Useful links: A link to MOH’s website, social media and other resources should also be added

• Should include print and download feature in various formats ( Image, PDF, CSV, JASON…etc)

• Interactive visualizer which alternates between charts, tables and maps as possible

• Contact information: email address of SAEO focal person and telephone number of SAEO

• Filter feature: By period and org unit

 8. Feedback

It is essential to gather regular feedback on the interface, content and performance related feedback using this platform.

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