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Home > Data Forms > Data Request Form

Data Request Form

Use this form to request data from the Network.

Please read the Network Protocol regarding data requests for acknowledgment requirements and applicable charges.

We can provide aggregate patient information by race, gender, age, primary cause of ESRD, certain co-morbids, state, county, zipcode of residence, and cause of death. Up-to-date provider listing and ESRD Patient Prevalant zip code reports are currently listed in the Publications Tab of this website. Pease be specific in the data you are requesting.

Note: All data requests are processed by the last week in each month.  Any data request received prior to that week will be processed in that month.  Requests received the last week of the month will be processed in the next month.

Note: Specific patient information will not be provided. Patient sensitive information should NOT be submitted through this form.  Patient sensitive information includes and is not limited to: first name, last name, patient initials, ssn, dob, address, etc. If request is patient specific, please call 919-855-0882.

• Name:
• Date:
• Organization:
• Email address:
• Phone number:
• Are these data going to be used for research? select one Yes No
• Are these data going to be used in publication? select one Yes No
• Please state below the data you require and the intended use of the data. Be very specific.