Office of Integrated Surveillance and Informatics Services Bureau of Infectious Disease Massachusetts Department of Public Health William A. Hinton State Laboratory Institute 305 South St. Boston, MA 02130 Email completed forms to [email protected] or fax to 617-983-6813

SURVEILLANCE DATA REQUEST FORM

Please note the Bureau of Infectious Disease employs the following data suppression rules unless a specialized agreement is in place to release more identifiable information: 1. If the population is > 50,000 the case count data may be released regardless of size 2. If the population is < 50,000, the case count must be 5 or greater in order to report out a specific value, otherwise, see #3. 3. If the population is < 50,000, and the case count is 4 or less, the case count must be reported as <5 regardless of the actual number 4. 0 cases may be reported regardless of population size For population numbers, refer to www.census.gov

Name:

Affiliation:

Address:

Telephone: Fax: Email: Requested completion date: (Allow a minimum of two weeks to process a request.) Reason for Request:

Disease(s) Requested: (See attached list on page two for a listing of diseases for which surveillance data is available) Time period of interest: (e.g., 2011-2013) Geographic location:  Statewide (Keep in mind the data suppression rules above if you are requesting  County-specific town-specific data.) Specify county or counties of interest: ______

 Town-specific Specify town or towns of interest (keeping in mind suppression rules above): ______

Rev. 1/7/2015 Office of Integrated Surveillance and Informatics Services Bureau of Infectious Disease Massachusetts Department of Public Health William A. Hinton State Laboratory Institute 305 South St. Boston, MA 02130 Email completed forms to [email protected] or fax to 617-983-6813 Please check conditions (s) of interest.

 Amebiasis  Measles  Anthrax  Melioidosis  Chikungunya virus infection  Meningococcal disease  Powassan virus infection  Monkeypox  Babesiosis  Mumps  Borrelia miyamotoi infection  Novel Coronavirus (SARS, MERS, etc.)  Botulism  Pertussis  Brucellosis  Plague  Calicivirus/Norovirus infection  Polio  Campylobacteriosis  Psittacosis  Chlamydia  Q fever  Creutzfeldt-Jakob disease  Rabies - human  Cryptococcus  Rickettsial pox  Cryptosporidiosis  Rocky Mountain spotted fever  Cyclosporiasis  Rubella  Dengue fever  Salmonellosis  Diphtheria  Shiga toxin producing organism infection  Eastern equine encephalitis (EEE) (e.g., E. coli O157:H7)  Ehrlichiosis  Shigellosis  Encephalitis  Streptococcus pneumoniae infection  Enterovirus infection  Syphillis  Giardiasis  Tetanus  Glanders  Trichinellosis  Gonorrhea  Tularemia  Group A streptococcus infection  Typhus fever  Group B streptococcus infection  Varicella virus infection (Chicken pox)  Hansen's disease (Leprosy)  Venezuelan equine encephalitis  Hantavirus infection  Vibriosis  Hemolytic uremic syndrome (HUS)  Viral hemorrhagic fevers (e.g., Ebola)  Hepatitis A  Viral meningitis  Hepatitis B  West Nile virus (WNV) infection  Hepatitis C  Yellow fever  Hepatitis D  Yersiniosis  Hepatitis E  Haemophilus influenzae infection If you are interested in an infectious disease not shown, please call 617-983-  HIV 6801 to inquire about data availability.

 Human granulocytic anaplasmosis Surveillance reports for HIV/AIDS may be found online:  Influenza http://www.mass.gov/eohhs/gov/departments/dph/programs/id/hivaids-  Legionellosis surveillance/surveillance/public-health-cdc-hivaids-surveillance-std-  Leptospirosis report.html  Listeriosis Surveillance reports for tuberculosis may be found online:  Lyme disease http://www.mass.gov/eohhs/gov/departments/dph/ programs/id/tb/public-  Lymphocytic choriomeningitis health-cdc-tb-statistics.html  Malaria Other selected disease specific surveillance reports may be found online: Rev. 1/7/2015 http://www.mass.gov/eohhs/gov/departments/dph/programs/id/ epidemiology/