The National Study Center for Trauma and EMS

MCTSA Data Request Form

Your request is very important to us. We provide the following format only as a guide in helping us expedite your request as quickly and efficiently as possible using Maryland Data. Please help us by providing us with as much detail about your request as possible. Data requests may take up to 15 business days to be completed. Thank you.

( * ) Indicates a required field, a response must be included in order to submit the form.

1.   ( * ) Please enter the requested due date for this data request:

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2.   ( * ) Please provide us with the following information so that we may service your request:

Name:     Company Name:     Email Address:     Phone Number:

3.   ( * ) What are your plans for using these data? (check all that apply)

1.    Plan an education program 2.    Include as part of a program 3.    Evaluate a program 4.    Assist with legislation 5.    Plan enforcement effort 6.    Media 7.    Strategic Highway Safety Plan (SHSP) 8.    Other - Please Specify:

4.   ( * ) Identify if there are any specific Maryland Highway Safety Office (MHSO) priority areas of interest: (check all that apply)

1    . Aggressive Driving 2.     Bicycles 3.     Distracted Driving 4.     Impaired Driving 5.     Mature Drivers 6.     Motorcycles 7.     Occupant Protection 8.     Pedestrians 9.     Younger Drivers 10.   Other - Please Specify:

5.    ( * ) Please include additional details about your request in the box below.