Behavioral Health EIS
Report Request Form

Section 1 - Contacts (To be filled out by SP Lead)

1. SP Lead Requestor: Other:	2. Contact Person(s): 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: Other:	3b. Post Report in: Other:
3c. Expected Report Due Date: (dd/mm/yyyy)	3d. SP Lead Priority: Other:
3e. Comment:

Section 3: Report Access Roles: (To be filled out by SP Lead)
Link to List of Roles (Opens in New Window)
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:

Behavioral Health EIS Report Request Form

Behavioral Health EIS
Report Request Form