SHEPS CENTER DATA REQUEST FORM
NC Health Professions Data
Chiropractor Data
Fill out this form, print, and fax it to:
NC Board of Chiropractic Examiners
174 Church Street North
Concord, NC 28025
Ms. Carol Hall, Executive Secretary
Phone: (704) 793-1342
Fax: (704) 793-1385
Attach a separate page describing the intended use for the labels/listing. Once
approval has been received by the Sheps Center, you will be contacted
with an estimated price and delivery date of the output. Contact
the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 if you have
questions or need additional information.
Type of Organization:
For-Profit (FP)
Non-Profit (NP)
Electronic Output Request Type: Check one or more
Name, address, specialty, county ($4.50/100 names: $100.00(NP)/$200(FP)
minimum)
All data available ($7.00/100 names: $200.00(NP)/$300(FP)
minimum)
Output format:
Tab-delimited
Comma-delimited
Fixed Field
Other (please specify):
SELECTION CRITERIA (check all that apply):
Activity Status:
Active
Inactive
Area Selection:
In-state
Out-of-state
Specific counties:
Other (please specify)
Practice Setting:
Unknown
Hospital - Non-federal
Clinic (Non-federal)
Practice Office (Non-federal)
Other Federal
Form of Employment:
Unknown
Solo (self-employed)
Non-solo (self-employed)
Individual Practitioner
Partnership/Group
Primary Specialty:
Unknown
No specialty
Neurology
Orthopedics
Roentgenology
Other specialty
Description of Request:
List other details of your request in the box below.
What order do you want the output sorted in?
NOTICE: Data are provided by the NC Board of Chiropractic Examiners
as of October each year and compiled by the Sheps Center. Address changes
are made only at the time of the annual update. Contact the Sheps Center
Data Coordinator at (919)966-7112 for more detailed information regarding
the Sheps Center files.
For NC Board of Chiropractic Examiners Use Only:
Approved by:______________________________________________ Date:________
Note to Board: Please send this form with approval to the Sheps Center Data
Coordinator:
Fax (919) 966-5764.
Updated 5/1/05