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:
Supervisor:
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)
