IT system - Data collection fields

Public Report Submission Form

Complete the applicable fields. Table 1 presents all information that the DUA Requester must provide.

Table 1: Public Report Submission Form

Category	Item
DUA Setup
DUA Type	Select (Contractor, Limited Dataset)
Organization Name	Insert Text
Requester Name	Insert Text
Requester Email	Insert Text
Requester Phone Number	Insert Text
Main Information
Project Name	Insert Text
Project Aim	Insert Text
Collaborating Organizations
Collaborating Organization Name	Insert Text
Country	Select (List of Countries)
Street Address	Insert Text
City	Insert Text
State	Select (List of States)
Zip Code	Insert Text
Data User(s)
Select Organization	Select (List of Organization and Collaborating Organization(s))
Select Data User’s Role	Select (Data Custodian, Data Recipient, or Direct Access)
First Name	Insert Text
Last Name	Insert Text
Email Address	Insert Text
Phone Number	Insert Text
Country	Select (List of Countries)
Street Address	Insert Text
City	Insert Text
State	Select (List of States)
Zip Code	Insert Text
Data File Extraction %/ Cohort	Select (List of percentages)
From	Select (List of years)
To	Select (List of years)
Extraction Types	Select (Q1, Q2, Q3, Q4)
States (if applicable)	Select (List of states)
Access Method	Select (Direct Access, Shipping, Both Direct Access and Shipping)
Access To Which Data Disseminator	Select (CCW/VRDC, IDR, Other, EFT)
Other
Add Comment	Insert Text
Special Instructions	Insert Text

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