Fillable Request to Change School or Childcare Site Administrator (Michigan Care Improvement Registry)

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Request to Change School or Childcare Site Administrator (Michigan Care Improvement Registry)

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May 2021 Request to Change Site Administrator Form for School and Childcares
Request to Change School or Childcare
Site Administrator in the MCIR
This form is for individuals assigned to be the new Site Administrator of an established School/Childcare site,
replacing the existing Site Administrator in the Michigan Care Improvement Registry, MCIR. This form is NOT
for adding any additional users on a site. Current site administrators should follow site administrator training
directions at www.mcir.org to add additional users.
Please fill out the form COMPLETELY.
1. Forms not completed will be returned to sender resulting in delay of the processing request.
2. If you are a current MCIR user submitting this form to add another school/childcare facility site to your
MCIR access when you are approved, then you may navigate between sites by choosing
GO TO NEW SITE under the My Site section of the MCIR Home Screen, (Figure 1).
3. If you are NOT a current MCIR user a MCIR PIN number will be sent to you via email from
MDHHS-MCIRHelp@michigan.gov . If you did not receive an email check your spam or
junk email folder.
4. FAX all forms to 517-763-0370 or scan and email to MDHHS-MCIRHelp@michigan.gov.
Please allow up to 48 hours for processing.
FOR ASSISTANCE CONTACT:
MCIR Support Services @ 1-888-243-6652
Monday – Friday
8:30 am – 4:30 pm
MDHHS-MCIRHelp@michigan.gov
Figure 1
Michigan Care Improvement Registry (MCIR)
Request to Change School/Childcare Site Administrator
In accordance with Public Act 540 of the Public Acts of 1996, Amended 2006, Act 91, the Michigan Department of Health and Human Services (MDHHS) has
established the Michigan Care Improvement Registry (MCIR) to record information regarding immunizations administered by health care providers. Access
to the MCIR is permitted for the sole purpose of providing information and documentation needed for immunization purposes. Users of the system must
refrain from employing the MCIR and data on the MCIR for any use other than that required to provide immunization services. Access to the MCIR data
base is permitted under the provisions of MCL 540.9201, 9206 and 9227. Access to MCIR data is under the terms and conditions prescribed by the
MDHHS. Improper use of the MCIR will result in revocation of the user’s access privileges. The MDHHS reserves the right to revoke a user’s access
privileges at any time, without notice.
Please read the following statements. If you agree to abide by these statements, please complete the information requested below and fax this agreement
to: 517-763-0370 or mail to: MDHHS-Division of Immunization, MCIR Support Services, 333 S Grand Ave, PO Box 30195, Lansing, MI 48909.
As a user of the Michigan Care Improvement Registry, I accept and agree to the following:
•
I will handle information or documents obtained through the MCIR in a confidential manner.
•
I will restrict my use of the MCIR to accessing information and generating documentation only as necessary to properly conduct the administration
and management of my duties as they relate to immunizations.
•
I understand that my transactions on the MCIR are logged and are subject to being audited.
•
I will not furnish information or documentation obtained through the MCIR to individuals for personal use nor to any individuals not directly involved
with the conduct of my duties as they relate to immunizations.
•
I will not falsify any document or data obtained through the MCIR.
•
I will not attempt to copy all or part of the database or the software used to access the MCIR database in any unauthorized fashion, nor attempt to
falsify or otherwise alter data in the MCIR database or otherwise violate the Michigan Computer Crime Law (MCL 333.791-333.797) or the Vital
Records Law (MCL 333.2894) summarized on the reverse side of this form.
•
I will carefully safeguard my access privileges and password for the MCIR and will not permit the use of my access privileges by any other person,
unless I have authorized such use.
•
I will report any threat to or violation of the MCIR security.
All fields required to be completed. Please print or type.
I have read the above security agreement and the prohibited acts provided on the reverse side of this form.
I understand this information and I agree to comply with the above provisions. Further, I understand any violation of
these provisions may result in termination of access privileges and/or recommendation for prosecution.
Fa
cility:
Physical
Address:
Street City State Zip County
Phone Number:
NOTE: If you are requesting access to multiple sites, please fill out one request form per site.
Current Site Administrator Information
New Site Administrator Information
Print New Site Administrator’s Name:
Do you have a MILogin ID ?
YES
NO
If yes, please provide:
E-mail Address:
Signature:
Date Signed:
This document is subject to revision or withdrawal at any time at the discretion of the Michigan Department of Health and Human Services. 7-2020
Print Current Site Administrator’s Name:
(This person will be removed from the MCIR site.)
Prohibited Acts
Michigan Care Improvement Registry Law
MCL 540.920, 540.9206, 540.9207, 540.9227
S
ec.540.9206(2) Before administering an immunizing agent to a child, a health care provider shall notify the parent, guardian or person in
loco parentis of the child, on a form provided by the department, of the right to object to the reporting requirement of
subsection(3).
S
ec 540.9206(3) Unless the parent, guardian or person in loco parentis of the child who received the immunizing agent objects by written
notice received by the health care provider prior to reporting, a health care provider shall report to the department each
immunization administered by the health care provider, pursuant to rules promulgated under section 9227. If the parent,
guardian or person in loco parentis of the child who was immunized objects to the reporting requirement of this subsection
by written notice received by the health care provider prior to notification, the health care provider shall not report the
immunization.
Sec 540.9207(2) The information contained in the registry is subject to the confidentiality and disclosure requirements of sections 2637 and
2888 and to the rules promulgated under section 9227. The department may access the information contained in the registry
when necessary to fulfill its duties under this code.
Vital Records Law
MCL 333.2894 (1) A person shall not:
(d)
Wilfully and knowingly obtain, possess, use, sell, furnish, or attempt to obtain, possess, use, sell, or furnish to another
person, for any purpose of deception, a counterfeited, altered, amended, or mutilated vital record or certified copy
thereof.
(e)
Wilfully and knowingly furnish or process a vital record or a certified copy of a vital record with the knowledge or
i
ntention that it be used for the purposes of deception.
(
2)
A
person shall not make, counterfeit, alter, amend, or mutilate a vital record or report required to be filed
M
CL 333.2898 A person who violates section 2894...is guilty of a misdemeanor punishable by imprisonment for not more than 1 year, or a
fine of not more than $1,000.00, or both.
Michigan Computer Crime Law
MCL 752.794 - 752.797
S
ec.752.794 A person shall not, for the purpose of devising or executing a scheme or artifice with intent to defraud or for the purpose of
obtaining money, property, or service by means of a false or fraudulent pretense, representation, or promise with intent to,
gain access to or cause access to be made to a computer, computer system, or computer network
Se
c 752.795 A person shall not intentionally and without authorization, gain access to, alter, damage, or destroy a computer, computer
system, or computer network, or gain access to, alter, damage, or destroy a computer software program or data contained in
a computer, computer system, or computer network
Se
c 752.796 A person shall not utilize a computer, computer system, or computer network to commit a violation of section 174 of Act
328 of the Public Acts of 1931...........being section 750.362 of the Michigan Compiled Laws. [Larceny by conversion]
Sec 752.
797 A person who violates this act, if the violation involves $100.00 or less, is guilty of a misdemeanor. If the violation involves
more than $100.00, the person is guilty of a felony, punishable by imprisonment for not more than 10 years, or a fine of not
more than $5,000.00, or both.
This document is subject to revision or withdrawal at any time at the discretion of the Michigan Department of Health and Human Services 08/2010
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Request to Change School or Childcare Site Administrator (Michigan Care Improvement Registry)

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Completed 3 June 2021

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