DWS-WRA 001
01/2012
MIS Reporting Request Form
Date _________________
User(s)/Requestor(s) ______________________________ E‐mail _________________________ Phone _______________
Select One
Division/Department
Other: ____________________ Program
_________________
(TANF, FS, WIA, UI, etc.)
Q
O
(No Report), explain:
UESTION
NLY
New/Ongoing Report
Ad‐hoc Report
Existing Report Modification ‐ Report Name: ______________________
If New/Ongoing, what is the frequency of the report?
Weekly
Monthly
Quarterly
Yearly
Other ______________________________
Report Reason/Motivation:
(Example: Legislative Request, Policy Change, etc.)
Has this request been made previously?
Yes
No
NOTE: You may attach the original request to this e‐mail
If yes, to whom and when?
T
IME FRAME ‐ What date is the data needed? __________
When will the report first be used? __________
Draft
Final
REPORT CRITERIA
(If this is a question only and no report is requested, enter N/A in the remaining required fields)
1. What data or changes would you like to see?
(Examples: 1) How many UI Claimants were in Salt Lake County within the past 3 months? 2) How many
children are receiving CHIP in the state of Utah? 3) How many TANF recipients have a HS diploma/GED?)
2. Across what time period do you want the data to cover?
(Example: Most recent quarter, State Fiscal Year, Federal Fiscal Year, Calendar Year, etc.)
3. How will the data be used?
(Example: Program Evaluation, Trend Reports, Public Information, etc.)
4. Who will be using the data?
(Example: Managers, Supervisors, Line Staff, Public, etc.)
5. How do you want the data displayed?
(Examples: 1) Case, worker, program level; 2) Sorted by program type and ESA, programs per customer by month, etc.)
**If you have a mock‐up of how you would like the report to be displayed, please send it as an attachment in the e‐mail
request.**
Please click the e-mail link (DWS_Data@utah.gov) to submit this request.
For users with the Free Acrobat
Reader application, e-mail the request to the above address using the "Attach to E-mail" option from the
File menu.
You will receive an e-mail response within 1 business day with the name of the Analyst who will
be working on your request.
Note: If this form is not filled out completely, the form may be returned to you for completion.