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JavaScript that displays the current date.
EIS Report Request Form
Date of Request:(mm/dd/yyyy)
Submitted by:
-Select-
Margaret Burke
Lori Geiger
Brandi Giguere
Terry Sandusky
Jeanne Tondreau
Stephen Turner
Other
Other:
Section 1 - Contacts (To be filled out by SP Lead)
1. SP Lead Requestor:
-Select-
AM - Steve Turner
- Chery Gliniewicz
CH - Lori Geiger
MH - Margaret Burke
MR - Terry Sandusky
Other
Other:
2. Contact Person(s):
-Select-
CH - Jeanne Tondreau
- Chery Gliniewicz
MH - Brandi Giguere
MR - TBA
Other
Other:
Section 2: Report Attributes: (To be filled out by SP Lead)
3. Name of Report: (Maximum of 21 characters)
3a. Report to be Posted on Module:
-Select-
Administer
Agreement Management
Assessments
Authorizations
Client Tracking
Notes
Organizations
People
Planning
Processes
Reportable Events
Reports
Search
Service Encounters
Other
Other:
3b. Post Report in:
-Select-
EIS Production
Other
Other:
3c. Expected Report Due Date: (dd/mm/yyyy)
3d. SP Lead Priority:
-Select-
One (High)
Two (Medium)
Three (Low)
Other
Other:
3e. Comment:
Section 3: Report Access Roles: (To be filled out by SP Lead)
Link to List of Roles
Agreement Management (Please check all that apply)
Agreement Management System Administrator:
Agreement Manager Read Only:
Agreement Administrator:
Administrator:
Contractor Read Only Role:
Report Development Role:
Other:
Children Services (Please check all that apply)
Administrator:
Administer Children's Services Roles:
Children Services Reports Access Role:
Children System Coordinator Role:
Quality Improvement Children Role:
Report Development Role:
Contractor Read Only Role:
Data Entry Role:
Other:
Mental Health (Please check all that apply)
Administrator:
MH Data Entry Role:
MH Direct Services Role:
MH CDC Role:
Report Development Role:
Contractor Read Only Role:
CO Quality Improvement Role:
CO System Operations MH Serv/Prog Dev Role:
CO System Operations Read Only Role:
Other:
Mental Retardation (Please check all that apply)
Administrator:
Advocate Role:
MR CO Investigation Role:
CO Quality Improvement Read Only Role:
Clinical Management Role:
Data Entry Role:
Direct Services Role:
Direct Servcies Financial Role:
MR Assistant Program Manager Role:
MR Plaintiffs Attorney Role:
MR QA Regional Coordinators Role:
MR QA Director Role:
MR Reports Access Role:
Program Management Role:
Resource Development Role:
System Management Role:
Training and Education Role:
Contractor Read Only Role:
Other:
