Staff List For Special Data Collection Forms
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ALAMEDA COUNTY Behavioral Health Care Services
C
’
G
S
L
S
D
C
F
LINICIAN
S
ATEWAY
TAFF
IST FOR
PECIAL
ATA
OLLECTION
ORMS
O
D
R
RGANIZATION
ATE
EQUESTED
C
P
ONTACT
ERSON
P
HONE
E
MAIL
CFE
FSP
UELP
Other ____________________
Data Collection Form name:
Please list staff persons to be included in staff lists within the data collection forms but who will not need access to
Clinician's Gateway. Staff needing access must submit a Clinician's Gateway Staff Authorization Request.
STAFF
LAST NAME
FIRST NAME
REPORTING UNIT
PROGRAM
NUMBER
SEND FORM TO:
System Support Staff:
IS System Support Services
Oakland, CA 94606
Help Desk Log # _______________________
Tel 510-567-8181, Fax 510-567-8161
QIC 28004
Date & Name__________________________
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