Health Insights Request

Name(Required)

First Last

Facility or Organization(Required)

Email(Required)

Phone(Required)

Suggested Dashboard or Report Title(Required)

This field is hidden when viewing the form

Desired Dashboard or Report Delivery Date

Level of Importance(Required)

Low

Medium

High

Critical

Is the dashboard or report(Required)

New

Modification

Dashboard or report to modify(Required)

Is there a similar dashboard or report?(Required)

Yes

How is existing/similar dashboard or report currently accessed?(Required)

Audience (Facilities report is requested for)(Required)

How often will the dashboard or report be accessed?(Required)

How often will the dashboard or report need to be refreshed?(Required)

Describe the Purpose of the Dashboard or Report.(Required)

What questions will the dashboard or report answer? What will the information be used for? Please be specific.

What conditions or criteria should the dashboard or report take into consideration?(Required)

Fields to display, inclusion or exclusion criteria such as hospitals or clinics, inpatient/ambulatory/emergency visits, age categories, etc. Be as specific as possible.

Please provide any additional comments such as desired dashboard or report layout.(Required)

South Dakota Health Link Dashboard or Report Development Request Form