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Description
Renal Lease Renewal Form document sample
Document Sample
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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