ADRC/AGING/TRIBAL User System Access Request



DEPARTMENT OF HEALTH SERVICESDivision of Public HealthF-02000 (04/2023)STATE OF WISCONSINADRC/AGING/TRIBAL USER SYSTEM ACCESS REQUESTSee accompanying instructions document F-02000A for additional information and submission details.SECTION 1: Purpose of Request FORMCHECKBOX Request new user access starting this date: FORMTEXT ?????Who previously held this role? FORMTEXT ????? FORMCHECKBOX Request additional access for an existing user starting this date: FORMTEXT ????? FORMCHECKBOX Delete user access on this date: FORMTEXT ????? FORMCHECKBOX Change the following user information (e.g., last name, change in work role): FORMTEXT ?????SECTION 2: User InformationFirst NameLast Name FORMTEXT ????? FORMTEXT ?????Agency NameFor Regional Agencies: County/Tribe Office FORMTEXT ????? FORMTEXT ?????Work AddressCityStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Work PhoneWork Email Address FORMTEXT ????? FORMTEXT ?????SECTION 3: User Work Role FORMCHECKBOX ADRC Specialist (select activities) FORMCHECKBOX I&A FORMCHECKBOX Options Counseling FORMCHECKBOX Enrollment Counseling FORMCHECKBOX Director/Manager/Supervisor of FORMTEXT ????? FORMCHECKBOX Tribal ADRS (select activities) FORMCHECKBOX Administrative/Support Staff for FORMTEXT ????? FORMCHECKBOX DBS FORMCHECKBOX Tribal DBS FORMCHECKBOX Benefit Specialist Program Assistant FORMCHECKBOX DCS FORMCHECKBOX Tribal DCS FORMCHECKBOX SHIP Volunteer/Counselor FORMCHECKBOX Fiscal Staff for FORMTEXT ????? FORMCHECKBOX EBS FORMCHECKBOX Tribal EBS FORMCHECKBOX Aging Staff (specify role) FORMTEXT ????? FORMCHECKBOX Other (specify role) FORMTEXT ?????SECTION 4: BADR Systems Requiring F-02000 Submission FORMCHECKBOX SharePoint: Enter WILMS username: FORMTEXT ????? FORMCHECKBOX ADRC/Aging FORMCHECKBOX DBS FORMCHECKBOX DCS FORMCHECKBOX EBS FORMCHECKBOX WellSky: Select all that are applicable to the role AND attach signed F-00044. FORMCHECKBOX SAMS IR: Read Only FORMCHECKBOX SAMS IR: Edit FORMCHECKBOX SAMS Aging FORMCHECKBOX SAMS DBS FORMCHECKBOX SAMS EBS FORMCHECKBOX SHIP Reporting System for benefit specialists and SHIP counselors. (The fields below are optional.)For SHIP OnlyDate of Birth (MM/DD/YYYY)GenderRace/Ethnicity FORMTEXT ????? FORMDROPDOWN FORMTEXT ?????Primary Language FORMCHECKBOX English FORMCHECKBOX ASL FORMCHECKBOX Chinese FORMCHECKBOX Korean FORMCHECKBOX Russian FORMCHECKBOX Spanish FORMCHECKBOX Vietnamese FORMCHECKBOX Other: (list) FORMTEXT ?????Secondary Language FORMCHECKBOX English FORMCHECKBOX ASL FORMCHECKBOX Chinese FORMCHECKBOX Korean FORMCHECKBOX Russian FORMCHECKBOX Spanish FORMCHECKBOX Vietnamese FORMCHECKBOX Other: (list) FORMTEXT ?????SECTION 5: SubmissionSupervisor NameSupervisor Phone Number FORMTEXT ????? FORMTEXT ?????Supervisor Email FORMTEXT ?????This form contains personally identifiable information (PII). The agency supervisor must submit the completed form via secure encrypted email to DHSBADRtech@dhs. SECTION 6: Other DHS Systems Requiring Additional Form SubmissionSystems listed in this section require different registration to gain access. See instructions F-02000A.Online ADRC and Benefit Specialist Learning Management System (LMS): Self-register via link.WILMS (for SharePoint): Self-register via link prior to submitting this form for SharePoint access.FHiC :Self-register via link and wait for approval email.WAMS (for CARES, ECF, or FSIA): Self-register via link.CARES and/or ECF: CARES Security Officer submits completed F-00476 to DHS CARES AIMS email.FSIA: Complete form under “FSIA-Request Access” and send it to DHS SOS Help email.Encounter: Send completed F-21334 to DHS BADRtech email. ................
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