System User Request Form by olliegoblue34

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									                                                                            System User Request Form
User Information:                                                             Add User:          Remove User:               Change User:
Name:                                                                     Work Location:


Role:                                                                     Department:


Email:                                                                    Manager/contact:


Phone:                                                                    UserName:


Vnode Name:


System Access for New User:
Home Hospital:
         SPH        VGH              RJH             RCH             KGH                Other:
User Type:
         Admin/Clerical              Triage Cord.                 CVT/Nurse                   Physician                      Other:
             Data Entry                                                                      Physician Type:
             Reports Only                                                                         Referring
                                                                                                  Diagnostics
                                                                                                  Interventional
                                                                                                  Surgeon
                                                                                                  Other

Will this user be using an existing                                           Yes
workstation?                                                                  No the Registry will need to be installed on a:
                                                                                     new workstation
                                                                                     replacement workstation
                                                                          Asset #:
Will this user be replacing an existing user?                                Yes: User name:
                                                                            Does this user still require registry access?    Yes   No
                                                                            If no, is this permanent?      Yes      No
                                                                             No: Is there a user that has the same access this
                                                                          user will need: name:
System Areas Required (if different or additional access than an existing user):
                          SPH                  VGH            RJH               RCH               KGH           Other:
 Cathlab                Reports            Reports           Reports           Reports           Reports           Reports
                        View               View              View              View              View              View
                        Data Entry         Data Entry        Data Entry        Data Entry        Data Entry        Data Entry
 Pre-Surgical           Reports            Reports           Reports           Reports           Reports           Reports
                        View               View              View              View              View              View
 Assessment
                        Data Entry         Data Entry        Data Entry        Data Entry        Data Entry        Data Entry
 Surgery/               Reports            Reports           Reports           Reports           Reports           Reports
                        View               View              View              View              View              View
 Pacemaker
                        Data Entry         Data Entry        Data Entry        Data Entry        Data Entry        Data Entry
Comments:



Authorizing Manager:_____________________                                          Date:____________________
   or Digital signature – Phone Verification     Signature



Authorizing Director: _____________________                                        Date:____________________
   or Digital signature – Phone Verification     Signature

								
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