Division Of Services For The Blind Employee Administration Request Form

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EMPLOYEE ADMINISTRATION
N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF SERVICES FOR THE BLIND
REQUEST FORM
 
1. NEW HIRE
If New Hire, Mode of Communication: Braille
Large Print
Regular Print
SEPARATION
(Personnel only: Deactivate NCID account
)
RETIREMENT
(Personnel only: Archive NCID account
)
NAME CHANGE
(Personnel only: If Name Change: NCID:
E-mail:
)
INTERNAL TRANSFER
2. EFFECTIVE DATE:
3. LEGAL NAME: (First Name, Middle Initial, Last Name)
4. PREFERRED NAME:
5. PREVIOUS NAME:
6. PHONE:
7. OFFICE LOCATION:
ASHEVILLE
CHARLOTTE
RALEIGH
GREENVILLE
FAYETTEVILLE
WINSTON-SALEM
WILMINGTON
EVAL. UNIT
REHAB. CENTER
DSS
8. PHYSICAL ADDRESS:
WEB MASTER/ BEAM ADMIN: (Jennifer.L.Ward@dhhs.nc.gov / 919-733-9822 ext. 217)
9. WORKING JOB TITLE:
10. COUNTIES SERVED:
11. TRANSFER FROM STATE OR LOCAL AGENCY: YES
NO
If yes, Where:
12. EMPLOYEE HAS WORKED FOR DVRS OR DSDHH: YES
NO
LAN ADMINISTRATOR: (Marvin.Gilmore@dhhs.nc.gov / 919-733-9822 ext. 227)
13. EMAIL ACCOUNT: YES
NO
14. EMAIL GROUPS:
DSB-ALL
DSB-ASHEVILLE
DSB-CAMPUS
DSB-CHARLOTTE
DSB-REHAB
DSB-EVALUATION_UNIT
DSB-FAYETTEVILLE
DSB-GREENVILLE
DSB-RDO
DSB-WILMINGTON
DSB-WINSTON-SALEM
DSB-FISHER
DSB-AT
DSB-SWB
DSB-SOCIALWORKERS
15. NEW HIRE PC LOCATION:
DSB HELP DESK ESS/ SECURITY/ BEAM ADMIN: (Debbie.Williams@dhhs.nc.gov / 919-733-9822 ext. 257)
16. RACF NUMBER AND PASSWORD FOR ESS: YES
NO
17. USER ID AND PASSWORD FOR ONLINE VERIFICATION: YES
NO
18. WORKER #
VR/ILR ONLY- NEEDS SUPERVISOR APPROVAL FOR AUTHORIZATIONS (1) YES (2) NO
19. BEAM DELEGATE:
REMOVE DELEGATE
DATE:
20. ASSIGN CASELOAD DURING VACANCY TO:
21. COMMENTS:
MANAGER/ SUPERVISOR
DATE
PHONE NUMBER
DSB- 0311 Issued10/06 Revised 02/07; 09/07; 04/09; 08/09; 09/10; 07/11
(page 1)
 

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