Data Request Form – Wyoming

The Data Request Form is the two-page Wyoming Department of Health, Vital Records Services form on which a requestor describes the data wanted, the purpose and full intended use, and the criteria for pulling it, so the office can review the request for appropriateness before completing it.

The form opens with a disclaimer. Vital Records charges for work above and beyond what it normally publishes, with rates based on the complexity of the request and on whether it will be repeated. The requestor and the authorizing signer are responsible for making sure the request meets minimum necessary and need-to-know standards, and a formal data use agreement may be required. Data received may be used only for the stated and approved purpose, may not be disclosed further, and must be disposed of properly after use.

The state's agency page explains that Wyoming is a closed record state, so records can only be released to those eligible to receive them. Requests for information under Wyoming Statute 35-1-426(b) may be made with this form.

Page 2 is a block labeled "For Division/Program Use Only", where the office records the date received, the decision and the date completed. It also holds definitions of de-identified data, limited data set, minimum necessary, need-to-know and key. This form is for data requests, not for ordering a copy of an individual birth, death, marriage or divorce record.

Anyone who wants Wyoming vital records data that Vital Records Services does not normally publish completes this form. That includes requestors who need counts or aggregate data, de-identified data, a limited data set, or individually identifiable information.

Conditions printed on the form:

• Research requests: if you are requesting individually identifiable information for research, you must attach the appropriate IRB form(s). Research requests for individually identifiable health information without individual authorization must first be approved by an IRB and be accompanied by verification of that approval and documentation meeting 45 CFR 164.512(i)(1)(i).
• Recurring requests: if you need the data on a recurring basis, the form must be submitted annually.
• Data recipients other than the requestor must be named on the form.
• The form requires a requestor signature, and the disclaimer also refers to an authorizing signer.

Do not use this form for a request the agency's own definitions do not cover: the state's page says Wyoming is a closed record state, and records are released only to those eligible to receive them. Division/Program staff complete the "For Division/Program Use Only" block, not the requestor.

Complete the form when you need Wyoming vital records data beyond what Vital Records Services normally publishes, and before you need the data, because the request is reviewed for appropriateness before it is completed. The form has a When needed line for the date you require the data. If you need the data on a recurring basis, such as monthly or quarterly, mark Recurring; the form states that it must be submitted annually. The form prints no processing time or fixed deadline, so ask Vital Records Services at (307) 777-7632 or [email protected] how long your request may take. Requests that involve research and individually identifiable information also need the IRB documentation described on the form, so gather it before you submit.

The form itself prints no mailing address, portal or email for returning it, and the agency page says only that requests under Wyoming Statute 35-1-426(b) may be remitted using the form. Confirm the way to return it with Vital Records Services before you send it.

• Phone: (307) 777-7632 for questions about the request.
• Email: [email protected].
• In person: Vital Records Services, 2300 Capitol Avenue, Hathaway Building, Cheyenne, WY 82002. Open to the public Monday through Thursday, 9am to 4pm, and Friday by appointment only, excluding holidays. Vital Records Services' contact line at that address is (307) 777-7591.

Send the signed form with any IRB forms or approval documentation the form requires for research requests. Work above what the office normally publishes is charged; the form's disclaimer explains how rates are set, and the office can tell you the amount that applies to your request. FillingPDF lets you fill out and download the PDF; submission follows the channels above.