Form Soc 883 - County Cmips Ii User Request Form Deactivate/reactivate User
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COUNTY CMIPS II USER REQUEST FORM
DEACTIVATE/REACTIVATE USER
USER INFORMATION
User’s Name:
First Name
Last Name
Action to be Taken
■ ■
■ ■
■ ■
■ ■
■ ■
Deactivate
Reactivate
Mr.
Mrs.
Ms.
Effective Date ( MM/DD/YYYY)
Authorizing Manager’s Name
Phone Number
(
)
Authorizing Manager’s Signature
Date
PORTAL
(UPDATE USER PROFILE SCREEN)
Action To Be Taken ( Options include: 1) Deactivate user’s account; 2) Reactivate user’s account;
3) Remove access to certain areas; 4) Restore access to certain areas)
■ ■
■ ■
■ ■
■ ■
Deactivate
Reactivate
Remove Access
Restore Access
■ ■
Inactive/Lockout (completed by Security Officer)
Assign Access Dates (MM/DD/YYYY) : Leave blank if no access is to be given
Web Portal
Start Date:
End Date:
Case Management
Start Date:
End Date:
Report Access
Start Date:
End Date:
Assign Portal Roles and Access Date (MM/DD/YYYY) : Leave blank if no access is to be given
Query and Sampling Tool
Start Date:
End Date:
Data Retention
Start Date:
End Date:
Security Administrator
Start Date:
End Date:
Security Officer
Start Date:
End Date:
System Generated Password
(completed by Security Officer)
CASE MANAGEMENT
(USER HOME/CLOSE USER/REOPEN SCREENS)
End Date:
Reassign Cases and Identify New Case Owner (Name)
Cases Reassigned (completed by Security Officer)
Reopen Previous Positions
■ ■
■ ■
■ ■
■ ■
Yes
No
Yes
No
REPORTING
(FOR USER ACCESS REACTIVATION ONLY)
Security Group
Y/N
■ ■
■ ■
No
Yes
CORE
■ ■
■ ■
No
Yes
SYSTEM ADMIN
■ ■
■ ■
No
Yes
HEALTH BENEFITS MANAGER
Security Officer/Administrator Signature
Date
SOC 883 (8/13)
PAGE 1
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Parent category: Legal