INDIVIDUAL USER PROFILE STANDALONE SECTION I INDIVIDUAL USER PROFILE

Individual User Profile

Stand-Alone

Check all

that apply:

Add a New User ID Mainframe Printer ID      

Modify Access Revoke a User ID

Change name on User ID (new user ID will not be issued for name changes)

Employed By:

DHS Branch No./Location:      

Contractor      

Other (specify): Hospital using State Trauma Registy

Name (print) First M.I. Last

     

User ID / RACF ID

N/A

Effective Date

     

Hospital Name

     

Position/Title

     

Email Address

     

Phone

(    )      -     

Extension

     

Employee ID #:

N/A

Work Address

     

City

     

State

     

Zip

     

Name (print) First M.I. Last

User ID / RACF ID

/

Effective Date

Cluster Name

Position/Title

Email Address

Phone

( )-

Extension

Employee ID #:

Work Address

City

State

Zip

Name (print) First M.I. Last

     

Signature

Today’s Date

10/17/2021

Hospital Name

     

Phone

     

Extension

     

Position/Title

     

Email