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Get Request For HIV Prevention Program Reports - California ...

Stor Name: Requestor Title: Organization: Telephone Number: ( Fax Number: ) ( ) E-mail Address: Date of Request (mm/dd/yyyy): Desired Date of Completion (mm/dd/yyyy): Return this completed form to the California Department of Public Health, Office of AIDS at: Leodatarequest cdph.ca.gov Note: Please allow at least two to four weeks for completion of data request. Program Planning/Evaluation 1.) Purpose of Data Request (mark all that apply): Internal Health Department Use Only Needs As.

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