Authorization Letter to Renew License by dvd19551

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Authorization Letter to Renew License document sample

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									                                              Enterprise-Wide Online Licensing System (EOL)
                                                                 Requirements Specification
                                                                      Appendix F: Inputs List

                                                                                                   March 15, 2010




      ID                       Name                          Process                 Sample Filename             Comments
 DWP-I-001     Application for Water Treatment      Water Operator Exam          DWP-I-001_App for Water        Fill-in form
               Operator Exam Form CDPH 8629         Application                  Treatment Op Exam
                                                                                 CDPH8629.pdf
 DWP-I-002     Application for Water Distribution   Water Operator Exam          DWP-I-002_App for Water        Fill-in form
               Operator Exam Form CDPH 8631         Application                  Dist Op Exam
                                                                                 CDPH8631.pdf
 DWP-I-003     Water Operator Certification         Water Operator
               Application                          Certification
 DWP-I-004     Water Operator Certification         Water Operator
               Renewal Notice                       Certification Renewal
 DWP-I-005     Water Supply Permit Application      Water Supply Permit          DWP-I-005_Water Supply         Fill-in form
                                                    Application                  Permit App.pdf
 DWP-I-006     Payment Submittal Form               Perform Cashiering           DWP-I-006_Payment              Fill-in form
                                                                                 Submittal Form.PDF
 DWP-I-007     Certificates of Completion           Water Operator Exam
                                                    Application; Water
                                                    Operator Certification
                                                    Renewal
 DWP-I-008     Official transcripts                 Water Operator Exam
                                                    Application
 DWP-I-009     Fees                                 Water Operator Exam
                                                    Application; Water
                                                    Operator Certification;
                                                    Water Operator
                                                    Certification Renewal;
                                                    Water Supply Permit
                                                    Application; Perform
                                                    Cashiering
 DWP-I-010     Organizational charts                Water Operator
                                                    Certification
 DWP-I-011     Job Descriptions                     Water Operator
                                                    Certification
 DWP-I-012     Letter from applicant’s supervisor   Water Operator
                                                    Certification
 DWP-I-013     Incident Report/Request for          Water Operator Certificate
               Sanctions                            Enforcement
 DWP-I-014     CORE (Online Reporting               Reconcile Deposits
               Expenditures) Report
 DWP-I-015     Emergency Notification Plan          Water Supply Permit
                                                    Application; Perform Water
                                                    System Inspection
 DWP-I-016     Technical Report Outline             Water Supply Permit
                                                    Application
 DWP-I-017     Large Water Systems Inspection       Perform Water System
               Schedule Report                      Inspection
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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                      March 15, 2010


      ID                      Name                            Process                  Sample Filename           Comments
 DWP-I-018     Previous Inspection Report            Perform Water System
                                                     Inspection
 DWP-I-019     Water Quality Inquiry (WQI)           Perform Water System
               reports                               Inspection
 DWP-I-020     Invoice data                          Issue Water System Billing
                                                     Notices
 DWP-I-021     Rebates, delinquencies, and other     Issue Water System Billing
               billing adjustment information        Notices
 DWP-I-022     Miscellaneous Payments                Perform Cashiering
 DWP-I-023     Deposit Transmittal                   Reconcile Deposits
 EMB-I-001     Medical Waste Facility Permit         Transfer Station/Off-Site     EMB-I-001_Med Waste          Fill-in form
               Application Form CDPH 8667            Treatment                     Facility Permit App
                                                     Facility/Alternative          CDPH8667.pdf
                                                     Treatment Technology
                                                     New Permit; Transfer
                                                     Station/Off-Site Treatment
                                                     Facility/Alternative
                                                     Treatment Technology
                                                     Permit Renewal
 EMB-I-003     Generator Registration Application    Waste Generation              EMB-I-003_Generator          Fill-in form
               Form CDPH 8550                        Facilities New Registration   Registration App
                                                     Process                       CDPH8550.doc
 EMB-I-004     Medical Waste Facility                Waste Generation              EMB-I-004_Med Waste          Fill-in form
               Management Plan Registration          Facilities New Registration   Facility Mgmt Plan
               Form CDPH 8550                        Process                       Registration CDPH8550.doc
 EMB-I-005     Trauma Scene and Medical Waste        Waste Hauler/Trauma           EMB-I-005_Trauma Scene-      Fill-in form
               Transporter Identification/Facility   Scene Practitioner New        Med Waste Transporter ID
               Utilization Form CDPH 8668            Authorization Process         CDPH8668.pdf
 EMB-I-006     Limited Quantity Hauling              Waste Hauler/Trauma           EMB-I-006_Limited Quantity   Fill-in form
               Exemption (LQHE) Application          Scene Practitioner New        Hauling Exempt App
               Form CDPH 8664                        Authorization Process         CDPH8664.pdf
 EMB-I-007     Supporting documentation              Transfer Station/Off-Site
                                                     Treatment
                                                     Facility/Alternative
                                                     Treatment Technology
                                                     New Permit




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                                              Enterprise-Wide Online Licensing System (EOL)
                                                                 Requirements Specification
                                                                      Appendix F: Inputs List

                                                                                                     March 15, 2010


      ID                      Name                          Process                  Sample Filename          Comments
 EMB-I-008     Fee                                 Transfer Station/Off-Site
                                                   Treatment
                                                   Facility/Alternative
                                                   Treatment Technology
                                                   New Permit; Enforcement
                                                   Process; Waste
                                                   Generation Facilities New
                                                   Registration Process;
                                                   Waste Generation
                                                   Facilities Registration
                                                   Renewal Process; Waste
                                                   Hauler/Trauma Scene
                                                   Practitioner New
                                                   Authorization Process;
                                                   Waste Hauler/Trauma
                                                   Scene Practitioner
                                                   Authorization Renewal
                                                   Process; Perform
                                                   Cashiering
 EMB-I-009     Facility Corrective Action Letter   Transfer Station/Off-Site
                                                   Treatment
                                                   Facility/Alternative
                                                   Treatment Technology
                                                   Permit Renewal;
                                                   Complaints/Incidents
                                                   Process
 EMB-I-010     Report of Alleged Spill or Unsafe   Complaints/Incidents
               Illegal Practice                    Process
 EMB-I-011     Disposal Contract                   Waste Hauler/Trauma
                                                   Scene Practitioner New
                                                   Authorization Process;
                                                   Waste Hauler/Trauma
                                                   Scene Practitioner
                                                   Authorization Renewal
                                                   Process
 EMB-I-012     Invoice copy                        Waste Hauler/Trauma
                                                   Scene Practitioner
                                                   Authorization Renewal
                                                   Process
 EMB-I-013     Batch List                          Reconcile Deposits
 EMB-I-014     CORE (Online Reporting              Reconcile Deposits
               Expenditures) Report
 EMB-I-015     Home Generated Sharps               Waste Generation              EMB-I-015_Home              Fill-in form
               Consolidation Application Form      Facilities New Registration   Generated Sharps
               CDPH 8663                           Process                       Consolidation App
                                                                                 CDPH8663.pdf
 FDB-I-001     Cannery License Application Form    License New Facility;         FDB-I-001_Cannery License   Fill-in form
               CDPH 8597                           Renew Food Processors,        Application CDPH8597.pdf
                                                   Drugs, Devices


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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                 March 15, 2010


      ID                     Name                           Process              Sample Filename             Comments
 FDB-I-002     Cold Storage or Refrigeration       License New Facility;    FDB-I-002_Cold Storage-         Fill-in form
               Facility License Application Form   Renew Food Processors,   Refrig Facility License App
               CDPH 8591                           Drugs, Devices           CDPH8591.pdf
 FDB-I-003     Food Safety Fee Exemption           License New Facility     FDB-I-003_Food Safety Fee       Fill-in form
               Request Form CDPH 8694                                       Exempt Request
                                                                            CDPH8694.pdf
 FDB-I-004     Frozen Food Locker Plant License    License New Facility;    FDB-I-004_Frozen Food           Fill-in form
               Application Form CDPH 8592          Renew Food Processors,   Locker Plant License App
                                                   Drugs, Devices           CDPH8592.pdf
 FDB-I-005     Processed Food Registration         License New Facility;    FDB-I-005_Proc Food             Fill-in form
               (PFR) Application North Form        Renew Food Processors,   Registration App No
               CDPH 8610                           Drugs, Devices           CDPH8610.doc
 FDB-I-006     Organic Processed Product           License New Facility;    FDB-I-006_Organic Proc          Fill-in form
               Registration Application Form       Renew Food Processors,   Prod Registration App
               CDPH 8593                           Drugs, Devices           CDPH8593.pdf
 FDB-I-007     Pet Food Processor License-         License New Facility     FDB-I-007_Pet Food Proc         Fill-in form
               Registration Application Form                                License-Registration App
               CDPH 8676                                                    CDPH8676.pdf
 FDB-I-008     Shellfish Handling and Marketing    License New Facility     FDB-I-008_Shellfish             Fill-in form
               Certificate Application Form CDPH                            Handling-Marketing Cert
               8642                                                         App CDPH8642.pdf
 FDB-I-009     Bottled Water Distributor License   License New Facility;    FDB-I-009_Bottled Water         Fill-in form
               Application Form CDPH 8590          Renew Food Processors,   Dist License App
                                                   Drugs, Devices           CDPH8590.pdf
 FDB-I-010     Private Water Source Operator       License New Facility;    FDB-I-010_Private Water         Fill-in form
               License Application Form CDPH       Renew Food Processors,   Source Op License App
               8594                                Drugs, Devices           CDPH8594.pdf
 FDB-I-011     Retail Water Facility License       License New Facility;    FDB-I-011_Retail Water          Fill-in form
               Application Form CDPH 8602          Renew Food Processors,   Facility License App
                                                   Drugs, Devices           CDPH8602.pdf
 FDB-I-012     Water Bottling Plant License        License New Facility;    FDB-I-012_Water Bottling        Fill-in form
               Application Form CDPH 8603          Renew Food Processors,   Plant License App
                                                   Drugs, Devices           CDPH8603.pdf
 FDB-I-013     Water Haulers License Application   License New Facility;    FDB-I-013_Water Haulers         Fill-in form
               Form CDPH 8605                      Renew Food Processors,   License App CDPH8605.pdf
                                                   Drugs, Devices
 FDB-I-014     Water Vending Machine Operator      License New Facility;    FDB-I-014_Water Vending         Fill-in form
               License Application Form CDPH       Renew Food Processors,   Machine Op License App
               8604                                Drugs, Devices           CDPH8604.pdf
 FDB-I-015     New Medical Device                  License New Facility     FDB-I-015_New Med Device        Fill-in form
               Manufacturing License Application                            Manu License App
               Form CDPH 72N                                                CDPH72N.pdf
 FDB-I-016     New Drug Manufacturing License      License New Facility     FDB-I-016_New Drug              Fill-in form
               Application Form CDPH 52N                                    Manufacturing License App
                                                                            CDPH52N.pdf




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                                              Enterprise-Wide Online Licensing System (EOL)
                                                                 Requirements Specification
                                                                      Appendix F: Inputs List

                                                                                                     March 15, 2010


      ID                      Name                          Process                  Sample Filename            Comments
 FDB-I-017     Home Medical Device Retailer        License New Facility;         FDB-I-017_Home Med            Fill-in form
               Exemptee License Application        Renew Food Processors,        Device Retailer Exempt
               Form CDPH 8695                      Drugs, Devices                License App CDPH8695.pdf
 FDB-I-018     Home Medical Device Retailer        License New Facility;         FDB-I-018_Home Med            Fill-in form
               License Application Form CDPH       Renew Food Processors,        Device Retailer License App
               8679                                Drugs, Devices                CDPH8679.pdf
 FDB-I-019     Out-of-State Home Medical Device    License New Facility          FDB-I-019_Out-of-St Home      Fill-in form
               Retailer Registration Application                                 Med Device Retailer Reg
               Form CDPH 8679O                                                   App CDPH8679O.pdf
 FDB-I-020     Biennial Drug Manufacturing         Renew Food Processors,        FDB-I-020_Drug Manu           Fill-in form
               License Renewal Application Form    Drugs, Devices                License Renewal App
               CDPH 52R                                                          CDPH52R.pdf
 FDB-I-021     Disclosure Statement – Human        Renew Food Processors,        FDB-I-021_Disclosure Stmt     Fill-in form
               Prescription Drug Manufactures      Drugs, Devices                CDPH53.pdf
               Form CDPH 53
 FDB-I-022     Biennial Medical Device             Renew Food Processors,        FDB-I-022_Med Device          Fill-in form
               Manufacturing License Renewal       Drugs, Devices                Manu License Renewal App
               Application Form CDPH 72R                                         CDPH72R.pdf
 FDB-I-023     Commodity Codes Form CDPH           Renew Food Processors,        FDB-I-023_Commodity           Fill-in form
               8675                                Drugs, Devices                Codes CDPH8675.pdf
 FDB-I-024     Export Document Application         Certify Food, Drug, Device,   FDB-I-024_Export              Fill-in form
               Form CDPH 8582                      Cosmetic for Export           Document Application
                                                                                 CDPH8582.pdf
 FDB-I-025     Processed Food Registration         License New Facility;         FDB-I-025_Proc Food           Fill-in form
               (PFR) Application South Form        Renew Food Processors,        Registration App So
               CDPH 8611                           Drugs, Devices                CDPH8611.doc
 FDB-I-026     Lab test results                    License New Facility
 FDB-I-027     NAMA certificate                    License New Facility
 FDB-I-028     Picture of vending machine          License New Facility
 FDB-I-029     Fee                                 License New Facility
 FDB-I-030     Work plan                           Inspect Food Processors,
                                                   Drugs and Devices
 FDB-I-031     Complaint                           Process Food, Drug,
                                                   Device Complaint; STAKE
                                                   (Stop Tobacco Access to
                                                   Kids Enforcement)
                                                   Program
 FDB-I-032     BOE tobacco retailer license        STAKE (Stop Tobacco
               inventory                           Access to Kids
                                                   Enforcement) Program
 FDB-I-033     STAKE contracts                     STAKE (Stop Tobacco
                                                   Access to Kids
                                                   Enforcement) Program
 FDB-I-034     STAKE work plan                     STAKE (Stop Tobacco
                                                   Access to Kids
                                                   Enforcement) Program

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                                                 Enterprise-Wide Online Licensing System (EOL)
                                                                    Requirements Specification
                                                                         Appendix F: Inputs List

                                                                                                       March 15, 2010


      ID                         Name                         Process                   Sample Filename              Comments
 FDB-I-035     Product labels                        License New Facility
 FDB-I-036     High school diploma                   License New Facility
 FDB-I-037     Training record                       License New Facility
 FOA-I-001     Amendments                            Issue Radioactive
                                                     Materials Billing Notices
 FOA-I-002     Checks                                Perform Cashiering;
                                                     Process Mail
 FOA-I-003     Billing Notices                       Perform Cashiering
 FOA-I-004     Accounting batch package              Reconcile Deposits
 FOA-I-005     Undelivered mail                      Process Returned Mail
 FOA-I-006     Billing amounts                       Sealed Source & Device
                                                     Billing
 FOA-I-007     Mail                                  Process Mail
 L&C-I-001     Verification of Current Nurse         Certification of New          LnC-I-001_Verification of        Fill-in form
               Assistant Certification Form CDPH     CNA/HHA/CHT                   Nurse Cert CDPH931.pdf
               931                                   Paraprofessionals
 L&C-I-002     Home Health Aide Certification        Certification of New          LnC-I-002_HHA Certification      Fill-in form
               List Form HS 183                      CNA/HHA/CHT                   List HS183.pdf
                                                     Paraprofessionals
 L&C-I-003     Nurse Assistant and/or Home           Certification of New          LnC-I-003_CNA-HHA Initial        Fill-in form
               Health Aide Initial Application       CNA/HHA/CHT                   Application HS283B.pdf
               Form HS 283B                          Paraprofessionals
 L&C-I-004     Certified Hemodialysis Technician     Certification of New          LnC-I-004_CHT Initial App        Fill-in form
               Initial/Renewal Application Form      CNA/HHA/CHT                   HS283F.pdf
               HS 283F                               Paraprofessionals
 L&C-I-005     Transmittal for Criminal              Certification of New          LnC-I-005_Trans for              Fill-in form
               Background Clearance Form HS          CNA/HHA/CHT                   Criminal Background Clr
               283I                                  Paraprofessionals             HS283I.pdf
 L&C-I-006     Request for Live Scan Service         Certification of New          LnC-I-006_Request for Live       Fill-in form
               Form BCII 8016                        CNA/HHA/CHT                   Scan Service BCII8016.pdf
                                                     Paraprofessionals;
                                                     Licensing and Certification
                                                     of Health Care Facilities
 L&C-I-007     Certified Nurse Assistant In-         Renewal Certification of      LnC-I-007_CNA In-Service         Fill-in form
               Service Training/Continuing           CNA/HHA/CHT                   Trng-CE HS283A.pdf
               Education Form HS 283A                Paraprofessionals
 L&C-I-008     Certified Nurse Assistant and/or      Renewal Certification of      LnC-I-008_CNA-HHA                Fill-in form
               Home Health Aide Renewal              CNA/HHA/CHT                   Renewal Application
               Application Form HS 283C              Paraprofessionals             HS283C.pdf
 L&C-I-009     Certified Home Health Aide In-        Renewal Certification of      LnC-I-009_Certified HHA In-      Fill-in form
               Service Training/Continuing           CNA/HHA/CHT                   Service Trng-CE
               Education Form HS 283H                Paraprofessionals             HS283H.pdf
 L&C-I-010     CNA/HHT Report of Misconduct          CNA/HHA/CHT                   LnC-I-010_CNA-HHT Report         Fill-in form
               Form HS 318                           Complaints/Incidents          of Misconduct HS318.pdf
                                                     Process

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                                             Enterprise-Wide Online Licensing System (EOL)
                                                                Requirements Specification
                                                                     Appendix F: Inputs List

                                                                                                        March 15, 2010


     ID                      Name                             Process                   Sample Filename               Comments
 L&C-I-011     Transmittal Application for           Perform Background            LnC-I-011_Trans App for           Fill-in form
               Criminal Background Investigation     Check on                      Criminal Background Inv
               Form HS 322                           CNA/HHA/ICF/ADHC              HS322.pdf
                                                     Professionals/HHL
                                                     Paraprofessionals and
                                                     Professionals/Investigate
                                                     Continuing Education (CE)
                                                     and In-Service Hours;
                                                     Licensing and Certification
                                                     of Health Care Facilities
 L&C-I-012     Application for Initial and Renewal   Training Program and CE       LnC-I-012_App for Initial-        Fill-in form
               Approval as Continuing Education      Provider Program              Ren Approval as CE
               Provider Form HS 192                  Approval; Renewal of          Provider HS192.pdf
                                                     Training Program and CE
                                                     Provider Program
 L&C-I-013     Nurse Assistant Certification         Training Program and CE       LnC-I-013_CNA Cert                Fill-in form
               Training Program Application HS       Provider Program              Training Program App
               276                                   Approval; Renewal of          HS276.pdf
                                                     Training Program and CE
                                                     Provider Program
 L&C-I-014     Daily Nurse Assistant Training        Training Program and CE       LnC-I-014_Daily Nurse             Fill-in form
               Program Schedule Form HS 276B         Provider Program              Assistant Trng Prog Sch
                                                     Approval; Renewal of          HS276B.pdf
                                                     Training Program and CE
                                                     Provider Program
 L&C-I-015     Disclosure of Ownership & Control     Training Program and CE       LnC-I-015_Disclosure of           Fill-in form
               Interest Statement Form HS 276D       Provider Program              Ownership Stmt
                                                     Approval; Renewal of          HS276D.pdf
                                                     Training Program and CE
                                                     Provider Program
 L&C-I-016     Director of Staff Development-        Training Program and CE       LnC-I-016_Director of Staff       Fill-in form
               Instructor Application Form HS        Provider Program              Dev-Instructor App
               279                                   Approval; Renewal of          HS279.pdf
                                                     Training Program and CE
                                                     Provider Program
 L&C-I-017     Nurse Assistant Orientation           Renewal of Training           LnC-I-017_CNA Orientation         Fill-in form
               Program Content Form HS 278A          Program and CE Provider       Program Content
                                                     Program                       HS278A.pdf
 L&C-I-018     In-Service Training Program Form      Renewal of Training           LnC-I-018_In-Service              Fill-in form
               HS 278B                               Program and CE Provider       Training Program
                                                     Program                       HS278B.pdf
 L&C-I-019     Licensure and Certification           Licensing and Certification   LnC-I-019_Licensure and           Fill-in form
               Application Form HS 200               of Health Care Facilities;    Certification Application
                                                     Renewal Licensing for         HS200.pdf
                                                     Health Care Facilities
 L&C-I-020     Applicant Individual Information      Licensing and Certification   LnC-I-020_Applicant               Fill-in form
               Form HS 215A                          of Health Care Facilities;    Individual Information
                                                     Renewal Licensing for         HS215A.pdf
                                                     Health Care Facilities

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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                       March 15, 2010


      ID                      Name                           Process                   Sample Filename              Comments
 L&C-I-021     Administrative Organization /        Licensing and Certification   LnC-I-021_Administrative         Fill-in form
               Organization Structure Form HS       of Health Care Facilities     Organization HS309.pdf
               309
 L&C-I-022     Transfer Agreement Between           Licensing and Certification   LnC-I-022_Transfer               Fill-in form
               Form HS 602                          of Health Care Facilities     Agreement Between
                                                                                  HS602.pdf
 L&C-I-023     Request for Adult Day Health Care    Licensing and Certification   LnC-I-023_Request for            Fill-in form
               (ADHC) Moratorium Exemption          of Health Care Facilities     ADHC Center Moratorium
               Form CDPH 930                                                      Exempt CDPH930.pdf
 L&C-I-024     Civil Rights Compliance Review       Licensing and Certification   LnC-I-024_Civil Rights           Fill-in form
               Form DHCS 1051                       of Health Care Facilities     Compliance Review Form
                                                                                  DHCS1051.pdf
 L&C-I-025     Staffing/Service Arrangement         Licensing and Certification   LnC-I-025_Staffing Services      Fill-in form
               Form ADH 0006                        of Health Care Facilities     Arrangement ADH0006.pdf
 L&C-I-026     Proposal to Share Space Form         Licensing and Certification   LnC-I-026_Proposal to            Fill-in form
               ADH 0007                             of Health Care Facilities     Share Space ADH0007.pdf
 L&C-I-027     Program Flexibility Request Form     Licensing and Certification   LnC-I-027_ADHC Program           Fill-in form
               ADH 0014                             of Health Care Facilities     Flexibility Request
                                                                                  ADH0014.pdf
 L&C-I-028     Administrator and Program            Licensing and Certification   LnC-I-028_Administrator          Fill-in form
               Director Information Form CDA        of Health Care Facilities     and Program Director Info
               278                                                                CDA278.pdf
 L&C-I-029     Local Fire Inspection Authority      Licensing and Certification   LnC-I-029_Local Fire             Fill-in form
               Information Form CDA 282             of Health Care Facilities     Inspect Authority Info
                                                                                  CDA282.pdf
 L&C-I-030     Balance Sheet Form IMS 33            Licensing and Certification   LnC-I-030_Licensee               Fill-in form
                                                    of Health Care Facilities     Balance Sheet IMS33.pdf
 L&C-I-031     Cash Flow Forecast Form IMS 35       Licensing and Certification   LnC-I-031_Cash Flow              Fill-in form
                                                    of Health Care Facilities     Forecast IMS35.pdf
 L&C-I-032     Operating Budget Form IMS 37         Licensing and Certification   LnC-I-032_Operating              Fill-in form
                                                    of Health Care Facilities     Budget IMS37.pdf
 L&C-I-033     Request for Designation as a         Licensing and Certification   LnC-I-033_Request for            Fill-in form
               Rural Alternative ADHC Center        of Health Care Facilities     Designation as Rural ADHC
               Form ADH 0008                                                      Center ADH0008.pdf
 L&C-I-034     Medi-Cal Provider Agreement          Licensing and Certification   LnC-I-034_Instr for Comp of      Fill-in form
               Form DHCS 9098                       of Health Care Facilities     Medi-Cal Provider
                                                                                  Agreement DHCS9098.pdf
 L&C-I-035     Assurance of Compliance with the     Licensing and Certification   LnC-I-035_Assurance of           Fill-in form
               Dept of Health, Education, and       of Health Care Facilities     Compliance IMS32.pdf
               Welfare Regulations Form IMS 32
 L&C-I-036     Medi-Cal Participation Agreement     Licensing and Certification   LnC-I-036_Medi-Cal               Fill-in form
               Form IMS 36                          of Health Care Facilities     Participation Agreement
                                                                                  IMS36.pdf
 L&C-I-037     Disclaimer of Conflict of Interest   Licensing and Certification   LnC-I-037_Disclaimer of          Fill-in form
               Form MC 406                          of Health Care Facilities     Conflict of Interest
                                                                                  MC406.pdf

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                                              Enterprise-Wide Online Licensing System (EOL)
                                                                 Requirements Specification
                                                                      Appendix F: Inputs List

                                                                                                     March 15, 2010


      ID                     Name                           Process                  Sample Filename              Comments
 L&C-I-038     Criminal Records Clearance          Licensing and Certification   LnC-I-038_Criminal Record       Fill-in form
               Submissions Form CDPH 325           of Health Care Facilities     Clearance Submissions
                                                                                 CDPH325.pdf
 L&C-I-039     Program Flexibility Form CDPH       Licensing and Certification   LnC-I-039_Program               Fill-in form
               5000                                of Health Care Facilities     Flexibility CDPH5000.pdf
 L&C-I-040     AIT Application for Nursing Home    Licensing of Nursing Home     LnC-I-040_AIT App for NHA       Fill-in form
               Administrator State Examination     Administrators                State Exam-License
               and License Form CDPH 500                                         CDPH500.pdf
 L&C-I-041     Administrator in Training (AIT)     Licensing of Nursing Home     LnC-I-041_AIT Evaluation        Fill-in form
               Evaluation Report Form CDPH         Administrators                Report CDPH501.pdf
               501
 L&C-I-042     Application for AIT Program Form    Licensing of Nursing Home     LnC-I-042_App for AIT           Fill-in form
               CDPH 502                            Administrators                Program CDPH502.pdf
 L&C-I-043     Application for Nursing Home        Licensing of Nursing Home     LnC-I-043_App for NHA           Fill-in form
               Administrator State Examination     Administrators                State Exam CDPH503.pdf
               Form CDPH 503
 L&C-I-044     Application for Nursing Home        Licensing of Nursing Home     LnC-I-044_App for NHA           Fill-in form
               Administrator State Examination     Administrators                State Exam-License
               and License Form CDPH 504                                         CDPH504.pdf
 L&C-I-045     Application for Nursing Home        Licensing of Nursing Home     LnC-I-045_App for NHA           Fill-in form
               Administrator National              Administrators                National Exam
               Examination Form CDPH 505                                         CDPH505.pdf
 L&C-I-046     Application for Nursing Home        Licensing of Nursing Home     LnC-I-046_App for NHA           Fill-in form
               Administrator License Form CDPH     Administrators                License CDPH506.pdf
               506
 L&C-I-047     Application to Become a Provider    Licensing of Nursing Home     LnC-I-047_App to Become         Fill-in form
               of Continuing Education Form        Administrators                Provider of CE
               CDPH 508                                                          CDPH508.pdf
 L&C-I-048     Declaration and Request for         Licensing of Nursing Home     LnC-I-048_Dec-Req for           Fill-in form
               Replacement License Form HS         Administrators                Replacement License
               510                                                               HS510.doc
 L&C-I-049     Preceptor Continuing Education      Licensing of Nursing Home     LnC-I-049_Preceptor CE          Fill-in form
               Credit Application Form CDPH        Administrators                Credit Application
               515                                                               CDPH515.pdf
 L&C-I-050     NHAP Preceptor Training             Licensing of Nursing Home     LnC-I-050_NHAP Preceptor        Fill-in form
               Registration Form PH 516            Administrators                Training Registration
               (Application)                                                     PH516.doc
 L&C-I-051     Re-examination Application for      Licensing of Nursing Home     LnC-I-051_Re-exam App for       Fill-in form
               Nursing Home Administrator State    Administrators                NHA State Exam
               Examination Form CDPH 520                                         CDPH520.pdf
 L&C-I-052     Re-examination Application for      Licensing of Nursing Home     LnC-I-052_Re-exam App for       Fill-in form
               Nursing Home Administrator          Administrators                NHA National Exam
               National Examination Form CDPH                                    CDPH521.pdf
               521




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                                                  Enterprise-Wide Online Licensing System (EOL)
                                                                     Requirements Specification
                                                                          Appendix F: Inputs List

                                                                                                            March 15, 2010


      ID                      Name                              Process                    Sample Filename            Comments
 L&C-I-053     Special Accommodation Request          Licensing of Nursing Home       LnC-I-053_Special Acc          Fill-in form
               for Examination Form CDPH 523          Administrators; Renewal         Request for Exam
                                                      Licensing of Nursing Home       CDPH523.pdf
                                                      Administrators
 L&C-I-054     Master’s or Reciprocity Application    Licensing of Nursing Home       LnC-I-054_Mstr-Reciprocity     Fill-in form
               for Nursing Home Administrator         Administrators                  App for NHA Exam
               Exam Form CDPH 524                                                     CDPH524.pdf
 L&C-I-055     Application for Provisional License    Licensing of Nursing Home       LnC-I-055_App for              Fill-in form
               Form CDPH 525                          Administrators                  Provisional License
                                                                                      CDPH525.pdf
 L&C-I-056     Continuing Education Courses           Renewal Licensing of            LnC-I-056_CE Courses           Fill-in form
               Completed for Active License           Nursing Home                    Comp for Active License
               Renewal Form CDPH 509                  Administrators                  Ren CDPH509.pdf
 L&C-I-057     Instructor Application for C. E.       Renewal Licensing of            LnC-I-057_Instructor App for   Fill-in form
               Credit Form CDPH 511                   Nursing Home                    CE Credit CDPH511.pdf
                                                      Administrators
 L&C-I-058     License Renewal Affidavit for          Renewal Licensing of            LnC-I-058_License Renewal      Fill-in form
               Nursing Home Administrators            Nursing Home                    Affidavit for NHA HS512.pdf
               Form HS 512                            Administrators
 L&C-I-059     Licensee’s Request for Course          Renewal Licensing of            LnC-I-059_Licensee Req for     Fill-in form
               Approval Form CDPH 513                 Nursing Home                    Course Approval
                                                      Administrators                  CDPH513.pdf
 L&C-I-060     Request for Provider Renewal           Renewal Licensing of            LnC-I-060_Request for          Fill-in form
               Form CDPH 522                          Nursing Home                    Provider Renewal
                                                      Administrators                  CDPH522.pdf
 L&C-I-061     NHA/Facility Profile Sheet Form        Issue Citation for Failure to   LnC-I-061_NHA-Facility         Fill-in form
               CDPH 514                               Notify of Address Change        Profile Sheet CDPH514.doc
                                                      or Change of Facility
 L&C-I-062     Request to Change Address              Issue Citation for Failure to   LnC-I-062_Req to Change        Fill-in form
               and/or Name for CNA/HHA/CHT            Notify of Address Change        Addr-Name for CNA-HHA-
               Certification Form HS 0929             or Change of Facility           CHT HS0929.pdf
 L&C-I-063     Provider Request for Course            Licensing of Nursing Home       LnC-I-063_Prvdr Req for        Fill-in form
               Approval Form CDPH 518                 Administrators                  Course Approval
                                                                                      CDPH518.pdf
 L&C-I-064     Provider Request for Course            Licensing of Nursing Home       LnC-I-064_Prvdr Req for        Fill-in form
               Approvals for Seminars,                Administrators                  Course Approvals (Sem-
               Workshops, and Conferences                                             Wkshp-Conf) CDPH517.pdf
               Form CDPH 517
 L&C-I-065     Provider Request for Course            Licensing of Nursing Home       LnC-I-065_Prvdr Req for        Fill-in form
               Renewal Form CDPH 519                  Administrators                  Course Renewal
                                                                                      CDPH519.pdf
 L&C-I-066     Request for Citation Review            Issue Citations/Penalties
               Conference or Legal Action             for Facilities




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                                             Enterprise-Wide Online Licensing System (EOL)
                                                                Requirements Specification
                                                                     Appendix F: Inputs List

                                                                                                        March 15, 2010


      ID                      Name                          Process                    Sample Filename              Comments
 L&C-I-067     Application package                 Certification of New
                                                   CNA/HHA/CHT
                                                   Paraprofessionals;
                                                   Training Program and CE
                                                   Provider Program
                                                   Approval; Licensing and
                                                   Certification of Health Care
                                                   Facilities; Licensing of
                                                   Nursing Home
                                                   Administrators
 L&C-I-068     Clearance information               Certification of New
                                                   CNA/HHA/CHT
                                                   Paraprofessionals;
                                                   Renewal Certification of
                                                   CNA/HHA/CHT
                                                   Paraprofessionals; Perform
                                                   Background Check on
                                                   CNA/HHA/ICF/ADHC
                                                   Professionals/HHL
                                                   Paraprofessionals and
                                                   Professionals/Investigate
                                                   Continuing Education (CE)
                                                   and In-Service Hours
 L&C-I-069     Renewal application package         Renewal Certification of
                                                   CNA/HHA/CHT
                                                   Paraprofessionals;
                                                   Renewal of Training
                                                   Program and CE Provider
                                                   Program; Renewal
                                                   Licensing for Health Care
                                                   Facilities; Renewal
                                                   Licensing of Nursing Home
                                                   Administrators
 L&C-I-070     Exam results                        Certification of New
                                                   CNA/HHA/CHT
                                                   Paraprofessionals;
                                                   Renewal Certification of
                                                   CNA/HHA/CHT
                                                   Paraprofessionals
 L&C-I-071     Complaint Form                      CNA/HHA/CHT                    LnC-I-071_Complaint             Fill-in form
                                                   Complaints/Incidents           Against Health Facility -
                                                   Process; Training Program      Provider Form.pdf
                                                   and CE Provider Program
                                                   Complaints Process;
                                                   Facility Complaint
                                                   Investigations; Issue
                                                   Citations/Penalties for
                                                   Facilities; Nursing Home
                                                   Administrators
                                                   Complaints/Incidents
                                                   Process


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                                             Enterprise-Wide Online Licensing System (EOL)
                                                                Requirements Specification
                                                                     Appendix F: Inputs List

                                                                                                      March 15, 2010


      ID                     Name                             Process                  Sample Filename             Comments
 L&C-I-072     CORI, rap sheets                      Perform Background
                                                     Check on
                                                     CNA/HHA/ICF/ADHC
                                                     Professionals/HHL
                                                     Paraprofessionals and
                                                     Professionals/Investigate
                                                     Continuing Education (CE)
                                                     and In-Service Hours
 L&C-I-073     Court documents submitted with        Perform Background
               application                           Check on
                                                     CNA/HHA/ICF/ADHC
                                                     Professionals/HHL
                                                     Paraprofessionals and
                                                     Professionals/Investigate
                                                     Continuing Education (CE)
                                                     and In-Service Hours
 L&C-I-074     Applications received from registry   Perform Background
                                                     Check on
                                                     CNA/HHA/ICF/ADHC
                                                     Professionals/HHL
                                                     Paraprofessionals and
                                                     Professionals/Investigate
                                                     Continuing Education (CE)
                                                     and In-Service Hours
 L&C-I-075     Fee                                   Licensing and Certification
                                                     of Health Care Facilities;
                                                     Renewal Licensing for
                                                     Health Care Facilities;
                                                     Renewal Licensing of
                                                     Nursing Home
                                                     Administrators
 L&C-I-076     Plan of Corrective Action             Facility Complaint
                                                     Investigations; Nursing
                                                     Home Administrators
                                                     Complaints/Incidents
                                                     Process
 L&C-I-077     Survey process inputs                 Issue Citations/Penalties
                                                     for Facilities
 L&C-I-078     Request                               Process Public Record Act
                                                     Requests
 L&C-I-079     Affidavit Regarding Patient Money     Licensing and Certification   LnC-I-079_Affidavit           Fill-in form
               Form HS 400                           of Health Care Facilities     Regarding Patient Money
                                                                                   HS400.pdf
 L&C-I-080     Surety Bond Verification Form HS      Licensing and Certification   LnC-I-080_Surety Bond         Fill-in form
               402                                   of Health Care Facilities     Verification HS402.pdf
 L&C-I-081     Notice-Effective Date of Provider     Licensing and Certification   LnC-I-081_Notice-Eff Date     Fill-in form
               Agreement Form HS 328                 of Health Care Facilities     of Provider Agreement
                                                                                   HS328.pdf



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                                                Enterprise-Wide Online Licensing System (EOL)
                                                                   Requirements Specification
                                                                        Appendix F: Inputs List

                                                                                                        March 15, 2010


      ID                      Name                            Process                   Sample Filename             Comments
 L&C-I-082     Bed or Service Request Form HS        Licensing and Certification   LnC-I-082_Bed or Service       Fill-in form
               609                                   of Health Care Facilities     Request HS609.pdf
 L&C-I-083     Application for Medi-Cal              Licensing and Certification   LnC-I-083_App for Medi-Cal     Fill-in form
               Certification as a Primary Care       of Health Care Facilities     Cert as Primary Care Clinic
               Clinic Provider Form HS 269                                         Provider HS269.pdf
 L&C-I-084     Form CMS 370                          Licensing and Certification                                  Fill-in form
                                                     of Health Care Facilities
 L&C-I-085     Form CMS 377                          Licensing and Certification                                  Fill-in form
                                                     of Health Care Facilities
 L&C-I-086     Form LIC 413                          Licensing and Certification                                  Fill-in form
                                                     of Health Care Facilities
 L&C-I-087     Assurance of Compliance Form          Licensing and Certification                                  Fill-in form
               HHS 690                               of Health Care Facilities
 L&C-I-088     Form OMB 0900-0243                    Licensing and Certification                                  Fill-in form
                                                     of Health Care Facilities
 L&C-I-089     Form HS 268                           Licensing and Certification                                  Fill-in form
                                                     of Health Care Facilities
 L&C-I-090     Application for Cardiovascular        Licensing and Certification   LnC-I-090_App for              Fill-in form
               Surgery Service Form CDPH 241         of Health Care Facilities     Cardiovascular Surgery
                                                                                   Service CDPH241.pdf
 L&C-I-091     Application for Chronic Dialysis      Licensing and Certification   LnC-I-091_App for Chronic      Fill-in form
               Service Form CDPH 242                 of Health Care Facilities     Dialysis Service
                                                                                   CDPH242.pdf
 L&C-I-092     Application for Dental Service        Licensing and Certification   LnC-I-092_App for Dental       Fill-in form
               Form CDPH 243                         of Health Care Facilities     Service CDPH243.pdf
 L&C-I-093     Application for Nuclear Medicine      Licensing and Certification   LnC-I-093_App for Nuclear      Fill-in form
               Service Form CDPH 245                 of Health Care Facilities     Medicine Service
                                                                                   CDPH245.pdf
 L&C-I-094     Application for Outpatient Service    Licensing and Certification   LnC-I-094_App for              Fill-in form
               Form CDPH 246                         of Health Care Facilities     Outpatient Service
                                                                                   CDPH246.pdf
 L&C-I-095     Application for Pediatric Service     Licensing and Certification   LnC-I-095_App for Pediatric    Fill-in form
               Form CDPH 247                         of Health Care Facilities     Service CDPH247.pdf
 L&C-I-096     Application for Perinatal Unit Form   Licensing and Certification   LnC-I-096_App for Perinatal    Fill-in form
               CDPH 248                              of Health Care Facilities     Unit CDPH248.pdf
 L&C-I-097     Application for Podiatric Service     Licensing and Certification   LnC-I-097_App for Podiatric    Fill-in form
               Form CDPH 249                         of Health Care Facilities     Service CDPH249.pdf
 L&C-I-098     Application for Psychiatric Unit      Licensing and Certification   LnC-I-098_App for              Fill-in form
               Form CDPH 250                         of Health Care Facilities     Psychiatric Unit
                                                                                   CDPH250.pdf
 L&C-I-099     Application for Radiation Therapy     Licensing and Certification   LnC-I-099_App for Radiation    Fill-in form
               Service Form CDPH 251                 of Health Care Facilities     Therapy Service
                                                                                   CDPH251.pdf
 L&C-I-100     Application for Renal Transplant      Licensing and Certification   LnC-I-100_App for Renal        Fill-in form
               Center Form CDPH 252                  of Health Care Facilities     Transplant Center
                                                                                   CDPH252.pdf
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                                                Enterprise-Wide Online Licensing System (EOL)
                                                                   Requirements Specification
                                                                        Appendix F: Inputs List

                                                                                                      March 15, 2010


      ID                      Name                           Process                   Sample Filename             Comments
 L&C-I-101     Application for Respiratory Care     Licensing and Certification   LnC-I-101_App for              Fill-in form
               Service Form CDPH 253                of Health Care Facilities     Respiratory Care Service
                                                                                  CDPH253.pdf
 L&C-I-102     Application for Social Service       Licensing and Certification   LnC-I-102_App for Social       Fill-in form
               Form CDPH 255                        of Health Care Facilities     Service CDPH255.pdf
 L&C-I-103     Application for Standby              Licensing and Certification   LnC-I-103_App for Standby      Fill-in form
               Emergency Medical Service            of Health Care Facilities     Emergency Med Svc
               Physician on Call Form CDPH 256                                    Physician on Call
                                                                                  CDPH256.pdf
 L&C-I-104     Application for Basic Emergency      Licensing and Certification   LnC-I-104_App for Basic        Fill-in form
               Medical Service Physician on Duty    of Health Care Facilities     Emergency Med Svc
               Form CDPH 257                                                      Physician on Duty
                                                                                  CDPH257.pdf
 L&C-I-105     Application for Comprehensive        Licensing and Certification   LnC-I-105_App for              Fill-in form
               Emergency Medical Service Form       of Health Care Facilities     Comprehensive Emergency
               CDPH 258                                                           Med Svc CDPH258.pdf
 L&C-I-106     Application for Rehabilitation       Licensing and Certification   LnC-I-106_App for              Fill-in form
               Center Form CDPH 259                 of Health Care Facilities     Rehabilitation Center
                                                                                  CDPH259.pdf
 L&C-I-107     Application for Occupational         Licensing and Certification   LnC-I-107_App for              Fill-in form
               Therapy Service Form CDPH 260        of Health Care Facilities     Occupational Therapy
                                                                                  Service CDPH260.pdf
 L&C-I-108     Application for Physical Therapy     Licensing and Certification   LnC-I-108_App for Physical     Fill-in form
               Service Form CDPH 261                of Health Care Facilities     Therapy Service
                                                                                  CDPH261.pdf
 L&C-I-109     Application for Speech Pathology-    Licensing and Certification   LnC-I-109_App for Speech       Fill-in form
               Audiology Service Form CDPH          of Health Care Facilities     Pathology-Audiology Service
               262                                                                CDPH262.pdf
 L&C-I-110     Application for Acute Respiratory    Licensing and Certification   LnC-I-110_App for Acute        Fill-in form
               Care Service Form CDPH 263           of Health Care Facilities     Respiratory Care Service
                                                                                  CDPH263.pdf
 L&C-I-111     Application for Burn Center Form     Licensing and Certification   LnC-I-111_App for Burn         Fill-in form
               CDPH 264                             of Health Care Facilities     Center CDPH264.pdf
 L&C-I-112     Application for Coronary Care        Licensing and Certification   LnC-I-112_App for Coronary     Fill-in form
               Service Form CDPH 265                of Health Care Facilities     Care Service CDPH265.pdf
 L&C-I-113     Application for Intensive Care       Licensing and Certification   LnC-I-113_App for Intensive    Fill-in form
               Newborn Nursery Service Form         of Health Care Facilities     Care Newborn Nursery
               CDPH 266                                                           Service CDPH266.pdf
 L&C-I-114     Application for Intensive Care       Licensing and Certification   LnC-I-114_App for Intensive    Fill-in form
               Service Form CDPH 267                of Health Care Facilities     Care Service CDPH267.pdf
 L&C-I-115     Application for Supplemental         Licensing and Certification   LnC-I-115_App for              Fill-in form
               Services Approval Form CDPH          of Health Care Facilities     Supplemental Services
               268                                                                Approval CDPH268.pdf
 L&C-I-116     Client Accommodations Analysis       Licensing and Certification   LnC-I-116_Client               Fill-in form
               Form CDPH 709                        of Health Care Facilities     Accommodations Analysis
                                                                                  CDPH709.pdf


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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                       March 15, 2010


      ID                      Name                            Process                   Sample Filename               Comments
 L&C-I-117     Fire Safety Inspection Request        Licensing and Certification   LnC-I-117_Fire Safety            Fill-in form
               Form STD 850                          of Health Care Facilities     Inspection Request
                                                                                   STD850.pdf
 L&C-I-118     Medicare Enrollment Application       Licensing and Certification   LnC-I-118_Medicare               Fill-in form
               Form CMS 855A                         of Health Care Facilities     Enrollment Application
                                                                                   CMS855A.pdf
 L&C-I-119     Health Insurance Benefit              Licensing and Certification   LnC-I-119_Health Insurance       Fill-in form
               Agreement Form CMS 1561               of Health Care Facilities     Benefit Agreement
                                                                                   CMS1561.pdf
 L&C-I-120     Health Insurance Benefit              Licensing and Certification   LnC-I-120_Health Insurance       Fill-in form
               Agreement Rural Clinic Form CMS       of Health Care Facilities     Benefit Agreement Rural
               1561A                                                               Clinic CMS1561A.pdf
 L&C-I-121     Home Health Agency Survey and         Licensing and Certification   LnC-I-121_HHA Survey and         Fill-in form
               Deficiencies Report Form CMS          of Health Care Facilities     Deficiencies Report
               1572                                                                CMS1572.pdf
 L&C-I-122     Instructions for Completing           Licensing and Certification   LnC-I-122_Instr for Comp         Fill-in form
               Request to Establish Eligibility to   of Health Care Facilities     Request to Provide Rural
               Participate in the Health Insurance                                 Health Clinic Svcs
               for the Aged and Disabled                                           CMS29.pdf
               Program to Provide Rural Health
               Clinic Services Form CMS 29
 L&C-I-123     Long Term Care Facility               Licensing and Certification   LnC-I-123_LTC Facility App       Fill-in form
               Application for Medicare and          of Health Care Facilities     for Medicare and Medicaid
               Medicaid Form CMS 671                                               CMS671.pdf
 L&C-I-124     Form CMS 1856                         Licensing and Certification                                    Fill-in form
                                                     of Health Care Facilities
 L&C-I-125     Medically Underserved or Health       Licensing and Certification   LnC-I-125_Medically              Fill-in form
               Professional Shortage Areas Form      of Health Care Facilities     Underserved or Health Prof
               HS 610                                                              Shortage HS610.pdf
 LFS-I-001     Application for Clinical Laboratory   License New Clinical Lab;     LFS-I-001_App for Clinical       Fill-in form
               License Form LAB 144                  Renew Clinical Lab            Lab License LAB144.pdf
                                                     License
 LFS-I-002     Application for Additional Clinical   License New Clinical Lab      LFS-I-002_App for Addtl          Fill-in form
               Laboratory Testing Sites Form                                       Clinical Lab Test Sites
               LAB 144B                                                            LAB144B.pdf
 LFS-I-003     Disclosure of Ownership and           License New Clinical Lab      LFS-I-003_Disclosure of          Fill-in form
               Control Interest Statement Form                                     Ownership Stmt
               LAB 1513                                                            LAB1513.pdf
 LFS-I-004     Laboratory Personnel Report Form      License New Clinical Lab;     LFS-I-004_Laboratory             Fill-in form
               LAB 116                               Renew Clinical Lab            Personnel Report
                                                     License                       LAB116.pdf
 LFS-I-005     Laboratory Testing Declaration        License New Clinical Lab;     LFS-I-005_Lab Testing            Fill-in form
               Form LAB 144A                         Renew Clinical Lab            Declaration LAB144A.pdf
                                                     License
 LFS-I-006     Director’s Attestation Form LAB       License New Clinical Lab;     LFS-I-006_Directors              Fill-in form
               183                                   Renew Clinical Lab            Attestation LAB183.pdf
                                                     License

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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                     March 15, 2010


      ID                     Name                            Process                  Sample Filename               Comments
 LFS-I-007     CLIA Application Form CMS 116         License New Clinical Lab                                     Fill-in form
 LFS-I-008     CLIA Laboratory Personnel Report      License New Clinical Lab    LFS-I-008_Lab Personnel          Fill-in form
               Form CMS 209                                                      Report CMS209.pdf
 LFS-I-009     Application for Clinical Laboratory   License New Clinical Lab;   LFS-I-009_App for Clinical       Fill-in form
               License Form LAB 144OS                Renew Clinical Lab          Lab License (out of st)
                                                     License                     LAB144OS.pdf
 LFS-I-010     Laboratory Personnel Qualification    License New Clinical Lab;   LFS-I-010_Lab Personnel          Fill-in form
               Form LAB 168                          Renew Clinical Lab          Qual LAB168.pdf
                                                     License
 LFS-I-011     Annual Test Volume of California      License New Clinical Lab;   LFS-I-011_Annual Test Vol        Fill-in form
               Specimens Form LAB 167                Renew Clinical Lab          of CA Specimens
                                                     License                     LAB167.pdf
 LFS-I-012     Application for Clinical Laboratory   License New Clinical Lab    LFS-I-012_App Clinical Lab       Fill-in form
               Registration Form LAB 155                                         Registration LAB155.pdf
 LFS-I-013     CLIA Renewal Application Form         Renew Clinical Lab          LFS-I-013_ CLIA Renewal          Fill-in form
               CMS 35                                License                     Application CMS35.pdf
 LFS-I-015     Tissue Bank License New               License New Tissue Bank     LFS-I-015_Tissue Bank            Fill-in form
               Application Form LAB 172                                          License New App
                                                                                 LAB172.pdf
 LFS-I-016     Personnel Report Form LAB 169         License New Tissue Bank;    LFS-I-016_Tissue Bank            Fill-in form
                                                     Renew Tissue Bank           Personnel Report
                                                     License; License New        LAB169.pdf
                                                     Blood Bank
 LFS-I-017     Assisted Reproductive Technology      License New Tissue Bank;    LFS-I-017_ART                    Fill-in form
               (ART) Questionnaire Form LAB          Renew Tissue Bank           Questionnaire LAB170.pdf
               170                                   License
 LFS-I-018     Tissue Bank Contact Person for        License New Tissue Bank;    LFS-I-018_Tissue Bank            Fill-in form
               Data Sheet Form LAB 184               Renew Tissue Bank           Contact Person LAB184.pdf
                                                     License
 LFS-I-019     Tissue Bank Renewal Form LAB          Renew Tissue Bank           LFS-I-019_Tissue Bank            Fill-in form
               171                                   License                     License Renewal App
                                                                                 LAB171.pdf
 LFS-I-020     Biologics License Application         License New Blood Bank      LFS-I-020_Biologics License      Fill-in form
               Form LAB 114                                                      Application LAB114.pdf
 LFS-I-021     Biologics Renewal License             Renew Blood Bank            LFS-I-021_Biologics              Fill-in form
               Application Form LAB 175              License                     Renewal License Application
                                                                                 LAB175.pdf
 LFS-I-022     Cytotechnologist (CLM)                Issue New Occupational      LFS-I-022_Application for        Fill-in form
               Application Form LAB 124              License                     Cytotechnologist License
                                                                                 LAB124.pdf
 LFS-I-023     Phlebotomy                            Issue New Occupational      LFS-I-023_Phlebo Tech Cert       Fill-in form
               Technician Certification              License                     Application LAB182.pdf
               Application Form LAB 182
 LFS-I-024     LFS-I-024_PHM Trainee Approval-       Issue New Occupational      LFS-I-024_PHM Trainee            Fill-in form
               Testing-Licensing Form LAB 129        License                     Approval-Testing-Licensing
                                                                                 LAB129.pdf

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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                        March 15, 2010


      ID                      Name                              Process                 Sample Filename            Comments
 LFS-I-025     Clinical Laboratory Scientist (MTA)     Issue New Occupational                                    Fill-in form
               Application Form LAB 160                License
 LFS-I-026     Clinical Chemist Scientist (MTC)        Issue New Occupational                                    Fill-in form
               Application Form LAB 160                License
 LFS-I-027     Clinical Immunohematologist             Issue New Occupational                                    Fill-in form
               Scientist (MTD) Application Form        License
               LAB 160
 LFS-I-028     Clinical Microbiologist Scientist       Issue New Occupational                                    Fill-in form
               (MTE) Application Form LAB 160          License
 LFS-I-029     Clinical Toxicologist Scientist         Issue New Occupational                                    Fill-in form
               (MTF) Application Form LAB 160          License
 LFS-I-030     Clinical Cytogeneticist Scientist       Issue New Occupational                                    Fill-in form
               (MTO) Application Form LAB 160          License
 LFS-I-031     Clinical Genetic Molecular-             Issue New Occupational                                    Fill-in form
               Biologist Scientist (MTP)               License
               Application Form LAB 160
 LFS-I-032     Clinical Hematologist Scientist         Issue New Occupational                                    Fill-in form
               (MTQ) Application Form LAB 160          License
 LFS-I-033     Clinical Histocompatibility Scientist   Issue New Occupational                                    Fill-in form
               (MTR) Application Form LAB 160          License
 LFS-I-034     Clinical Lab Bioanalyst or Clinical     Issue New Occupational       LFS-I-034_Clinical Lab       Fill-in form
               Lab Director License Application        License                      Bioanalyst-Dir License App
               Form LAB 161                                                         LAB161.pdf
 LFS-I-035     Clinical Scientist Trainee (TRL)        Issue New Occupational                                    Fill-in form
               Application Form LAB 156                License
 LFS-I-036     Application for Clinical Laboratory     Renew Clinical Lab                                        Fill-in form
               License Renewal Form LAB 144R           License
 LFS-I-037     Limited License (OBZ)                   Renew Occupational
                                                       License
 LFS-I-038     Clinical Laboratory Personnel           Renew Clinical Lab           LFS-I-038_Clinical Lab       Fill-in form
               License Renewal Continuing              License; Renew               License CE Summary
               Education Summary Form LAB              Occupational License; CE     LAB177.pdf
               177                                     Annual Audit of 5% of
                                                       Licensees
 LFS-I-039     Complaint Form LAB 163                  Facility Complaints          LFS-I-039_Complaint Form     Fill-in form
                                                       Management,                  LAB163.pdf
                                                       Enforcement, and Appeal
 LFS-I-040     Unsuccessful (2 of 3) PT Report         Perform Lab Proficiency      No sample available –
               (Report 153)                            Testing                      generated from OSCAR
 LFS-I-041     Individual Laboratory Profile           Perform Lab Proficiency      No sample available –
               (Report 155)                            Testing                      generated from OSCAR
 LFS-I-042     Public Health Microbiologist            Public Health                LFS-I-042_PHM Cert           Fill-in form
               Certification Application Form LAB      Microbiologist Testing and   Application LAB129.pdf
               129                                     Licensing



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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                       March 15, 2010


      ID                      Name                            Process                  Sample Filename               Comments
 LFS-I-043     Certifying Organization Application    Certifying Organization
                                                      Examination Approval and
                                                      Renewal Process
 LFS-I-044     Application for Continuing             CE Accrediting Agency       LFS-I-044_CEAA                   Fill-in form
               Education Accrediting Agency           Approval Process            Application LAB178.pdf
               Form LAB 178
 LFS-I-045     CE Accrediting Agency Renewal          CE Accrediting Agency       LFS-I-045_CEAA Renewal
               Application                            Renewal Process             Application.pdf
 LFS-I-046     Application to Train Clinical          CLS/MLT/Phlebotomy          LFS-I-046_App for CLS            Fill-in form
               Laboratory Scientist Trainees          Training School Approval    Training School Approval
               Form LAB 153                           and Inspections             LAB153.pdf
 LFS-I-048     Laboratory Personnel Report Out-       License New Clinical Lab;   LFS-I-048_Lab Personnel          Fill-in form
               of-State Form LAB 116OS                Renew Clinical Lab          Report LAB116OS.pdf
                                                      License
 LFS-I-049     Blood Bank Personnel Report                                        LFS-I-049_Blood Bank             Fill-in form
               Form LAB 118                                                       Personnel Report
                                                                                  LAB118.doc
 LFS-I-050     Medical Laboratory Technician          Issue New Occupational                                       Fill-in form
               Application Form LAB 186               License
 LFS-I-051     Application for Clinical Laboratory    Renew Clinical Lab          LFS-I-051_Renewal of             Fill-in form
               Registration Renewal Form LAB          License                     Clinical Lab Registration
               155R                                                               LAB155R.pdf
 LFS-I-052     Application to Train Clinical          CLS/MLT/Phlebotomy          LFS-I-052_App for CLS Ltd        Fill-in form
               Laboratory Scientist Trainees in       Training School Approval    Training School Approval
               Limited Technical Areas Form LAB       and Inspections             LABN119.pdf
               N119
 LFS-I-053     Application for Phlebotomy             CLS/MLT/Phlebotomy          LFS-I-053_App for Phlebo         Fill-in form
               Training Program Approval Form         Training School Approval    Training School Approval
               LAB 180                                and Inspections             LAB180.pdf
 LFS-I-054     Eligible Clinical Laboratory           CLS/MLT/Phlebotomy          LFS-I-054_ Eligible CLS Ltd      Fill-in form
               Scientist Limited Trainees Form        Training School Approval    Trainees LABN148.pdf
               LAB N148                               and Inspections
 LFS-I-055     Notification for Clinical Laboratory   CLS/MLT/Phlebotomy          LFS-I-055_Notification for       Fill-in form
               Scientist Limited Trainees Form        Training School Approval    CLS Ltd Trainees
               LAB N147                               and Inspections             LABN147.pdf




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                                             Enterprise-Wide Online Licensing System (EOL)
                                                                Requirements Specification
                                                                     Appendix F: Inputs List

                                                                                            March 15, 2010


      ID                     Name                           Process             Sample Filename         Comments
 LFS-I-056     Fee                                 License New Clinical Lab;
                                                   Renew Clinical Lab
                                                   License; License New
                                                   Tissue Bank; Renew
                                                   Tissue Bank License;
                                                   License New Blood Bank;
                                                   Renew Blood Bank
                                                   License; Issue New
                                                   Occupational License;
                                                   Renew Occupational
                                                   License; Process Public
                                                   Information/Records/Contr
                                                   olled Correspondence
                                                   Requests; CE Accrediting
                                                   Agency Renewal Process
 LFS-I-057     Supporting documentation (i.e.,     License New Clinical Lab;
               articles of incorporation,          License New Tissue Bank;
               documentation of director’s         Renew Tissue Bank
               qualifications, etc.)               License; License New
                                                   Blood Bank; Issue New
                                                   Occupational License
 LFS-I-058     Tissue Bank Site Lease              License New Tissue Bank
               Agreement
 LFS-I-059     Business Permit & Fictitious Name   License New Tissue Bank;
               Permit                              License New Blood Bank
 LFS-I-060     Ownership Substantiation            License New Tissue Bank;
                                                   License New Blood Bank
 LFS-I-061     Employee & Director Resumes         License New Tissue Bank;
                                                   License New Blood Bank
 LFS-I-062     Policies & Procedures               License New Tissue Bank;
                                                   License New Blood Bank
 LFS-I-063     Resumes or BRN numbers for          Renew Tissue Bank
               new employees                       License
 LFS-I-064     Checks Cleared Reports              Renew Tissue Bank
                                                   License
 LFS-I-065     Blood Bank Site Lease Agreement     License New Blood Bank
 LFS-I-066     Baccalaureate Certificate Title     Issue New Occupational
                                                   License
 LFS-I-067     Transcripts                         Issue New Occupational
                                                   License; Public Health
                                                   Microbiologist Testing and
                                                   Licensing
 LFS-I-068     List of Passed/Failed               Issue New Occupational
                                                   License
 LFS-I-069     Disk of Passed                      Issue New Occupational
                                                   License



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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                  March 15, 2010


      ID                     Name                           Process                 Sample Filename         Comments
 LFS-I-070     Plan of Correction (POC)            Survey and Inspections for
                                                   Licensing and Re-
                                                   licensing; Facility
                                                   Complaints Management,
                                                   Enforcement, and Appeal;
                                                   Perform Lab Proficiency
                                                   Testing;
                                                   CLS/MLT/Phlebotomy
                                                   Training School Approval
                                                   and Inspections
 LFS-I-071     Bureau of Criminal Identification   Perform Background
               and Information Report              Check
 LFS-I-072     Request for information             Process Public
                                                   Information/Records/Contr
                                                   olled Correspondence
                                                   Requests
 LFS-I-073     Lab Results                         Perform Lab Proficiency
                                                   Testing
 LFS-I-074     Letter of Completion                Public Health
                                                   Microbiologist Testing and
                                                   Licensing
 LFS-I-075     Exam Request                        Public Health
                                                   Microbiologist Testing and
                                                   Licensing
 LFS-I-076     Lab Aspire templates for summary    Public Health
               and quarterly reports               Microbiologist Testing and
                                                   Licensing
 LFS-I-077     Acceptance Letter                   Certifying Organization
                                                   Examination Approval and
                                                   Renewal Process
 LFS-I-078     Renewal Packet                      Certifying Organization
                                                   Examination Approval and
                                                   Renewal Process
 LFS-I-079     Accediting Agency Directions for    CE Accrediting Agency
               Renewal                             Renewal Process
 LFS-I-080     Course List                         CE Accrediting Agency
                                                   Renewal Process
 LFS-I-081     Continuing Education Certificates   CE Annual Audit of 5% of
                                                   Licensees
 LFS-I-082     California Accrediting Agency       CE Annual Audit of 5% of
               Verification Spreadsheet            Licensees
 LFS-I-083     Application to Train Medical        CLS/MLT/Phlebotomy                                     Fill-in form
               Laboratory Technician Form LAB      Training School Approval
               185                                 and Inspections
 LFS-I-084     Continuing Education Waiver         Renew Occupational           LFS-I-084_CE Waiver       Fill-in form
               Request Form LAB 158                License                      Request LAB158.pdf


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                                                 Enterprise-Wide Online Licensing System (EOL)
                                                                    Requirements Specification
                                                                         Appendix F: Inputs List

                                                                                                     March 15, 2010


      ID                      Name                            Process                 Sample Filename             Comments
 LFS-I-085     Application for Duplicate License                                 LFS-I-085_App for Duplicate    Fill-in form
               Form LAB 176                                                      License LAB176.pdf
 LFS-I-086     Application for Inactive Status                                   LFS-I-086_App for Inactive     Fill-in form
               Form LAB 179                                                      Status LAB179.pdf
 RAM-I-001     Allegation                            Perform Radioactive
                                                     Materials Investigation
 RAM-I-002     Report of Notification                Perform Radioactive
                                                     Materials Investigation
 RAM-I-003     Report of Incident                    Perform Emergency
                                                     Response
 RCS-I-001     Radiologic Technology Certificate     Certify Radiation Machine   RCS-I-001_RT Certificate       Fill-in form
               Application Form CDPH 8200            Operators                   App CDPH8200.pdf
 RCS-I-002     Application for a Certificate in      Certify Radiation Machine   RCS-I-002_Mammo                Fill-in form
               Mammographic Radiologic               Operators                   Radiologic Tech Cert App
               Technology Form CDPH 8200M                                        CDPH8200M.pdf
 RCS-I-003     Radiologic Technologist               Certify Radiation Machine   RCS-I-003_RT Fluoroscopy       Fill-in form
               Fluoroscopy Permit Application        Operators                   Permit App CDPH8218.pdf
               Form CDPH 8218
 RCS-I-004     CA Licentiate Supervisor and          Certify Radiation Machine   RCS-I-004_CA Licentiate        Fill-in form
               Operator Permits Application Form     Operators                   Sup-Op Permits
               CDPH 8230                                                         CDPH8230.pdf
 RCS-I-005     CA Radiology Supervisor and           Certify Radiation Machine   RCS-I-005_CA Radiology         Fill-in form
               Operator Certificate (Radiologists    Operators                   Sup-Op Cert (Rad only)
               only) Form CDPH 8231                                              CDPH8231.pdf
 RCS-I-006     X-Ray Technician Limited Permit       Certify Radiation Machine   RCS-I-006_X-Ray Tech LP        Fill-in form
               Application Form CDPH 8232            Operators                   App CDPH8232.pdf
 RCS-I-007     X-Ray Technician Bone                 Certify Radiation Machine   RCS-I-007_X-Ray Tech BD        Fill-in form
               Densitometry Permit Application       Operators                   Permit App
               Form CDPH 8232BD                                                  CDPH8232BD.pdf
 RCS-I-008     CA Supervisor and Operator            Certify Radiation Machine   RCS-I-008_CA Sup-Op Cert       Fill-in form
               Certificate Special Renewal           Operators                   (Sp Renewal App)
               Application Form CDPH 8238SRA                                     CDPH8238SRA.pdf
 RCS-I-009     Nuclear Medicine Technology           Certify Radiation Machine   RCS-I-009_Nuclear Med          Fill-in form
               Certificate Application Form CDPH     Operators                   Tech Cert App
               8435                                                              CDPH8435.pdf
 RCS-I-010     X-Ray Technician Digital              Certify Radiation Machine   RCS-I-010_X-Ray Tech           Fill-in form
               Authorization Application Form        Operators                   Digital Auth App
               CDPH 9054                                                         CDPH9054.doc
 RCS-I-012     Radiation Machine Registration        Register Radiation          RCS-I-012_Rad Machine          Fill-in form
               (RMR) Application Form RH 2261        Machine; NOV Program;       Registration RH2261.pdf
                                                     Issuance of CA Approval
                                                     Certificate for
                                                     Mammography Equipment;
                                                     Registration Unit
                                                     Radiological Document
                                                     Review


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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                         March 15, 2010


      ID                      Name                            Process                    Sample Filename            Comments
 RCS-I-013     Application for Mammography           Issuance of CA Approval        RCS-I-013_Mammo Facility-     Fill-in form
               Facility-Machine Certification Form   Certificate for                Machine Cert
               CDPH 8623                             Mammography Equipment          CDPH8623.pdf
 RCS-I-014     Matter Requiring                      Issuance of CA Approval                                      Fill-in form
               Investigation/Inspection Form RHB     Certificate for
               5010                                  Mammography Equipment
 RCS-I-015     Notice of Violation and Radiation     Issuance of CA Approval
               Users Declaration (NOV-RUD)           Certificate for
                                                     Mammography Equipment
 RCS-I-016     Application for Authorization to      Medical Physicist Approval     RCS-I-016_App for Med         Fill-in form
               Provide Therapeutic Physics                                          Physicist Auth Therapy
               Support Services or X-Ray                                            RHBRTP4254.doc
               Therapy Machine Calibrations in
               the State of California Form RHB
               RTP 4254
 RCS-I-017     Application for Authorization to      Medical Physicist Approval     RCS-I-017_App for Med         Fill-in form
               Provide Mammography Physics                                          Physicist Auth Mammo
               Supports Services in the State of                                    RHBMA4253.doc
               California Form RHB MA 4253
 RCS-I-018     Application for Approval of           New School Approval            RCS-I-018_App for Approval    Fill-in form
               Schools Teaching Diagnostic                                          of DG School CDPH-RHB
               Radiologic Technology Form                                           DG.doc
               CDPH-RHB DG
 RCS-I-019     Application for Approval of           New School Approval            RCS-I-019_App for Approval    Fill-in form
               Schools Teaching Radiologic                                          of FL School CDPH-RHB
               Technologist Fluoroscopy Permit                                      FL.doc
               Courses Form CDPH-RHB FL
 RCS-I-020     Application for Approval of           New School Approval            RCS-I-020_App for Approval    Fill-in form
               Schools Teaching Limited Permit                                      of LP-BD School CDPH-
               X-ray Technician-Bone                                                RHB LP-BD.doc
               Densitometry Category Form
               CDPH-RHB LP-BD
 RCS-I-021     Application for Approval of           New School Approval            RCS-I-021_App for Approval    Fill-in form
               Schools Teaching Limited Permit                                      of LP School CDPH-RHB
               Radiologic Technology Form                                           LP.doc
               CDPH-RHB LP
 RCS-I-022     Application for Approval of           New School Approval            RCS-I-022_App for Approval    Fill-in form
               Schools Teaching Therapeutic                                         of Thera School CDPH-RHB
               Radiologic Technology Form                                           TH.doc
               CDPH-RHB TH
 RCS-I-023     Limited Permit Clinical Affiliated    New School Approval            RCS-I-023_LP Clinical         Fill-in form
               Site Request Form CDPH 9053                                          Affiliated Site Request
                                                                                    CDPH9053.pdf
 RCS-I-024     Clinical Affiliation Request Form     New/Recertification Clinical                                 Fill-in form
                                                     Affiliated Site Approval
 RCS-I-025     Accommodation Request Form                                           RCS-I-025_Accommodation       Fill-in form
               CDPH 8625                                                            Request CDPH8625.pdf


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                                              Enterprise-Wide Online Licensing System (EOL)
                                                                 Requirements Specification
                                                                      Appendix F: Inputs List

                                                                                                      March 15, 2010


      ID                       Name                           Process                  Sample Filename               Comments
 RCS-I-026     Approved School Students Report                                     RCS-I-026_Approved              Fill-in form
               Form CDPH 8696                                                      School Students Report
                                                                                   CDPH8696.pdf
 RCS-I-027     Report of Change in Information                                     RCS-I-027_Rpt of Chng in        Fill-in form
               for Approved Schools Form CDPH                                      Info for Approved Schools
               8697                                                                CDPH8697.pdf
 RCS-I-028     Supporting documentation              Certify Radiation Machine
                                                     Operators
 RCS-I-029     Undelivered mail                      Process Returned Mail
 RCS-I-030     Reports of assembly                   NOV Program
 RCS-I-031     Accreditation information             Issuance of CA Approval
                                                     Certificate for
                                                     Mammography Equipment
 RCS-I-032     Federal certification information     Issuance of CA Approval
                                                     Certificate for
                                                     Mammography Equipment
 RCS-I-033     Physicist survey                      Issuance of CA Approval
                                                     Certificate for
                                                     Mammography Equipment
 RCS-I-034     Cease and Desist                      Issuance of CA Approval
                                                     Certificate for
                                                     Mammography Equipment
 RCS-I-035     Request for document review           Registration Unit
                                                     Radiological Document
                                                     Review
 RCS-I-036     Application Package                   Medical Physicist
                                                     Approval; New School
                                                     Approval; School
                                                     Recertification and Billing
                                                     Notices
 RCS-I-037     Allegation                            Perform Radiologic
                                                     Technology School
                                                     Inspection; Perform
                                                     Radiological Survey
 RCS-I-038     Inspection Finding                    Perform Radiological
                                                     Survey
 RCS-I-039     Payment                               School Recertification and
                                                     Billing Notices
 RCS-I-040     Returned mail                         Nonresponsive Facilities
 RCS-I-041     Notification from ICE                 Nonresponsive Facilities
 RCS-I-042     Application for Renewal of            Medical Physicist Approval    RCS-I-042_Renewal App for       Fill-in form
               Authorization to Provide                                            Med Physicist Auth Mammo
               Mammography Physics Support                                         RHBMA4253R .doc
               Services in the State of California
               Form RHB MA 4253R



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                                            Enterprise-Wide Online Licensing System (EOL)
                                                               Requirements Specification
                                                                    Appendix F: Inputs List

                                                                                                   March 15, 2010


      ID                     Name                           Process                   Sample Filename           Comments
 RCS-I-043     Application for a Therapy           Registration Unit            N/A                           Non-standard
               Authorization Measure               Radiological Document                                      letter from
                                                   Review                                                     facility
 RCS-I-044     Application for a Therapy           Registration Unit            N/A                           Non-standard
               Authorization to Treat              Radiological Document                                      letter from
                                                   Review                                                     facility
 RCS-I-045     Application for a Therapy           Registration Unit            N/A                           Non-standard
               Authorization to Treat –            Radiological Document                                      letter from
               Amendment                           Review                                                     facility
 RCS-I-046     Application for a Therapy           Registration Unit            N/A                           Non-standard
               Authorization – Final               Radiological Document                                      letter from
                                                   Review                                                     facility
 RCS-I-047     Application for an Exemption from   Registration Unit            N/A                           Non-standard
               Regulatory Requirements using       Radiological Document                                      letter from
               Handheld X-ray Machine in the       Review                                                     facility
               Healing Arts
 RCS-I-048     Bone Densitometer Supervisor &      Certify Radiation Machine    RCS-I-048_Bone                Fill-in form
               Operator Certificate Application    Operators                    Densitometer SO Cert App
               Form CDPH 8711                                                   CDPH8711.pdf
 RCS-I-049     Nuclear Medicine Technology         Certify Radiation Machine    RCS-I-049_Nuc Med Tech        Fill-in form
               Certificate Special Renewal         Operators                    Cert Spec Renewal App
               Application Form CDPH 8435SRA                                    CDPH 8435SRA.pdf
 RCS-I-050     Radiologic Technology Certificate   Certify Radiation Machine    RCS-I-050_RT Cert Spec        Fill-in form
               Special Renewal Application Form    Operators                    Renewal App CDPH
               CDPH 8200SRA                                                     8200SRA.pdf
 RCS-I-051     X-Ray Technician Bone               Certify Radiation Machine    RCS-I-051_X-Ray Tech BD       Fill-in form
               Densitometry Permit Special         Operators                    Permit Spec Renewal App
               Renewal Application Form CDPH                                    CDPH 8232BDSRA.pdf
               8232BDSRA
 RCS-I-052     X-Ray Technician Limited Permit     Certify Radiation Machine    RCS-I-052_X-Ray Tech LP       Fill-in form
               Special Renewal Application Form    Operators                    Spec Renewal App CDPH
               CDPH 8232SRA                                                     8232SRA.pdf
 RCS-I-053     Radiologic Technologist/X-ray       Certify Radiation Machine    RCS-I-053_RT X-ray Cert or    Fill-in form
               Technician Certificate or Permit    Operators                    Permit Renewal Notice
               Renewal Notice Form Rhbnot01                                     Rhbnot01.pdf
 RCS-I-054     Nuclear Medicine Technology         Certify Radiation Machine    RCS-I-054_NucMed Cert         Fill-in form
               Certificate Renewal Notice Form     Operators                    Renewal Notice (1st pg)
               Nucnot01                                                         Nucnot01.pdf; RCS-I-
                                                                                054_NucMed Cert Renewal
                                                                                Notice (2nd pg)
                                                                                Nucnot01.pdf
 RCS-I-055     X-ray Supervisor and Operator       Certify Radiation Machine    RCS-I-055_X-ray S-O Cert      Fill-in form
               Certificate or Permit Renewal       Operators                    or Permit Renewal Notice
               Notice Form Rhlnot01                                             Rhlnot01.pdf
 RML-I-001     Application for Radioactive         Perform Radioactive          RML-I-001_App for RML -       Fill-in form
               Materials License - Medical Form    Materials Licensing Action   Medical RH2000.pdf
               RH 2000


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                                               Enterprise-Wide Online Licensing System (EOL)
                                                                  Requirements Specification
                                                                       Appendix F: Inputs List

                                                                                                     March 15, 2010


      ID                      Name                          Process                  Sample Filename             Comments
 RML-I-002     Radioactive Material License        Perform Radioactive          RML-I-002_RML Application      Fill-in form
               Application Form RH 2050            Materials Licensing Action   RH2050.pdf
 RML-I-003     Radioactive Material License        Perform Radioactive          RML-I-003_RML Application      Fill-in form
               Application, Use of Sealed          Materials Licensing Action   SSD RH2050 IR.pdf
               Sources in Radiography Form RH
               2050IR
 RML-I-004     Application for Teletherapy         Perform Radioactive          RML-I-004_App for              Fill-in form
               Authorization Form RH 2000D         Materials Licensing Action   Teletherapy Auth
                                                                                RH2000d.pdf
 RML-I-005     Certificate of Disposition of       Perform Radioactive          RML-I-005_Cert of              Fill-in form
               Materials Form RH 5314              Materials Licensing Action   Disposition of Materials
                                                                                RH5314.pdf
 RML-I-006     Statement of Training and           Perform Radioactive          RML-I-006_Stmt of Training-    Fill-in form
               Experience Form RH 2050A            Materials Licensing Action   Experience RH2050A.pdf
 RML-I-007     Statement of Training and           Perform Radioactive          RML-I-007_Stmt of Trng-        Fill-in form
               Experience Limited Radiography      Materials Licensing Action   Exp Ltd Rad License Only
               License Only Form RH 2050RA                                      RH2050RA.pdf
 RML-I-008     Training and Experience Medical     Perform Radioactive          RML-I-008_Trng-Exp Med         Fill-in form
               Authorized User or Radiation        Materials Licensing Action   Auth User-Rad Safety
               Safety Officer Form RH 2000A                                     RH2000a.pdf
 RML-I-009     Application for Radioactive         Perform Radioactive          RML-I-009_App for RML          Fill-in form
               Material License of Broad Scope –   Materials Licensing Action   Broad Scope Type A
               Type A Form RH 2080                                              RH2080.pdf
 RML-I-010     Manifest                            Low-Level Radioactive        No standard form or format
                                                   Waste Tracking (LLRWT)
 RML-I-011     Generator Annual Report of          Low-Level Radioactive        No standard form or format
               Stored Materials                    Waste Tracking (LLRWT)
 RML-I-012     Supervisor Listing Report           Perform Radioactive
                                                   Materials Licensing Action
 RML-I-013     Document review request             Perform Radiological
                                                   Document Review
 RML-I-014     Survey request                      Perform Radiological
                                                   Survey
 RML-I-015     Laboratory Analysis Report          Perform Radiological
                                                   Survey
 RML-I-016     Application/Amendment Request       Sealed Source & Device
                                                   (SS&D) Safety Review
 RML-I-017     Application for X-ray Machine       Perform Radioactive          RML-I-017_X-ray Machine
               “Provisional” Industrial            Materials Licensing Action   Prov IR Cert App.pdf
               Radiographer Certificate
 XRay-I-001    DIQUAD Report                       Perform Radiation Machine    XRay-I-001_DIQUAD              Excel
                                                   Inspection                   Report.xls.xlsm                spreadsheet
 XRay-I-002    Inspector Itinerary Report          Perform Radiation Machine
                                                   Inspection



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                                            Enterprise-Wide Online Licensing System (EOL)
                                                               Requirements Specification
                                                                    Appendix F: Inputs List

                                                                                           March 15, 2010


      ID                     Name                           Process            Sample Filename         Comments
 XRay-I-003    List of Inspections Due Report      Perform Mammography
                                                   Machine Inspection
                                                   (State); Perform
                                                   Mammography Machine
                                                   Inspection (MQSA)
 XRay-I-004    Complaint/allegation                Perform Radiation Machine
                                                   Investigation




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