08/14/2020
*(First)
(Middle Initial)
*Employee
*LAUSD E-Mail Account
*Position
*Primary Phone
Alternate Phone
*School/Office (all assigned schools)
*Location Code(s)
NEW USERS COMPLETE THIS SECTION: (*Check One)
Principal, Assistant Principal, APEIS, APSCS
Special Day Program Teacher or Transition Service Facilitator (TSF) with manager access
Resource Specialist Teacher (RST) with manager access
BII’s Only (Service Tracking Access)
Special Ed Clerk Central/Local District Classified HCA Other:
Nurse: (School, LVN, etc.)
P
rovider Type:
Required: Immediate Supervisor:
Print Name (This person will assign you to all your locations)
DIS/Related Service Provider (APE, LAS, Psychologist, etc.)
P
rovider Type:
Required:
Related Service Immediate Supervisor:
Print Name (This person will assign you to all your locations)
REQUIRED SIGNATURES: Your application will be rejected if either signature below are missing. Only Directors and Principals
can sign their own application.
I understand that I have access to confidential student records and I cannot discuss or share these records with unauthorized personnel.
(Print) User’s Name Signature Title Date
*Approved:
(Print) User’s Name Signature Title Date
CHANGE/DELETE EXISTING ACCOUNT
Remove Location(s):
Change of Location: From: To:
C
hange Title/Role: From: To:
No longer an Employee (Inactivate User)
:
(Print) User’s Name Signature Title Date
For Welligent training, sign up through MyPLN by logging into https://achieve.lausd.net/mypln
with your Single Sign-On account.
If you need an e-mail account or forgot your e-mail password call the ITD Helpdesk at (213) 241-5200 option 2.
Questions? Call the Welligent Support Section at (213)241-5200 option 8.
Attach this form to an online ticket for Welligent Support at: https://lausd-myit.onbmc.com
LAUSD EMPLOYEE FORM – ALL REQUIRED (*) FIELDS MUST BE COMPLETED IN ORDER TO PROCESS
click to sign
signature
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click to sign
signature
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signature
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