LEO User Profile Form
New User Change User Inactivate User
Basic Information
First name: MI: Last Name:
Birth Date:
Gender: Male Female
Phone: Email:
Hire Date: Termination Date:
System Information
Staff Type (Please only choose one staff type that best describes their position):
Access IT Dietician
Crisis Staff Administrative Registered Nurse
CMHSP Billing Medical Physician Supports Coordinator
CEO Nurse Practitioner Supports Coordinator Assistant
Case Manager Occupational Therapist Supervisor
Contract Provider Billing Peer Support Support Staff
Contract Manager Physician’s Assistant Therapist
Direct Care Worker Psychiatrist Utilization Management
Director Quality Management Specialist Medical Assistant
Executive Director Recipient Rights Other:
Home Manager Resident
Intern Respite Worker
If this staff is a Supervisor, list the individuals they will oversee:
Assigned Location(s):
Tasks user will be responsible for in LEO (please be as detailed as possible):
This User will need a FAS System Login ID (CAFAS & PECFAS)
LW# 8-05.02-A