STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COUNTY CMIPS II USER REQUEST FORM
DEACTIVATE/REACTIVATE USER
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
USER INFORMATION
PORTAL
(UPDATE USER PROFILE SCREEN)
CASE MANAGEMENT
(USER HOME/CLOSE USER/REOPEN SCREENS)
REPORTING
(FOR USER ACCESS REACTIVATION ONLY)
Action to be Taken
Deactivate
Reactivate
Ye s
No
Ye s
No
Ye s
No
Cases Reassigned
(completed by Security Officer)
Ye s
No
Reopen Previous Positions
Ye s
No
User’s Name:
First Name Last Name
Mr.
Mrs.
Ms.
Action To Be Taken (
Options include:
1) Deactivate user’s account;
2) Reactivate user’s account;
3) Remove access to certain areas;
4) Restore access to certain areas)
Deactivate
Reactivate
Remove Access
Restore Access
Inactive/Lockout
(completed by Security Officer)
Effective Date (
MM/DD/YYYY)
Authorizing Manager’s Signature
Assign Access Dates
(MM/DD/YYYY)
: Leave blank if no access is to be given
Assign Portal Roles and Access Date
(MM/DD/YYYY)
: Leave blank if no access is to be given
Web Portal Start Date: End Date:
Case Management Start Date: End Date:
Report Access Start Date: End Date:
Query and Sampling Tool Start Date: End Date:
Data Retention Start Date: End Date:
Security Administrator Start Date: End Date:
Security Officer Start Date: End Date:
System Generated Password
(completed by Security Officer)
Authorizing Manager’s Name Phone Number
( )
Date
Security Officer/Administrator Signature
SOC 883 (8/13) PAGE 1
Date
Security Group
CORE
SYSTEM ADMIN
HEALTH BENEFITS MANAGER
Y/N
Reassign Cases and Identify New Case Owner (Name)
End Date:
INSTRUCTIONS ON FILLING OUT COUNTY CMIPS II USER REQUEST FORM
Deactivate/Reactivate User
These instructions are to assist a requesting agency in completing the User Request form. Please be
sure to complete the form in its entirety. If you need assistance or have questions, please contact the
CDSS Adult Programs Systems Unit at (916) 551-1003.
USER INFORMATION
Action To Be Taken – Check appropriate box.
User’s Name – Check appropriate box and then enter first and last name of User.
Effective
Date (MM/DD/YYYY)
– Enter effective date. Month and day must have two digits
(e.g.01/05/2012)
.
Authorizing Manager’s Name – Enter first and last name of Authorizing Manager.
Authorizing Manager’s Signature – Enter Authorizing Manager’s signature here.
Date – Enter date Authorizing Manager signed form.
PORTAL
Action To Be Taken – Check appropriate box.
Assign Access Dates
(MM/DD/YYYY)
: Leave blank if no access is to be given
Enter date for each applicable area. If no specific end date is available, it is recommended that
“2099” be used in “End Date” fields.
Assign Portal Roles and Access Dates
(MM/DD/YYYY)
: Leave blank if no
access is to be given – Enter date for each applicable area. If no specific
end date is available, it is recommended that “2099” be used in “End Date” fields.
System Generated Password (
completed by Security Officer)
– For Reactivation Only.
Upon completion of the reactivation, enter the system generated
password assigned to the user.
SOC 883 (8/13) PAGE 2
CASE MANAGEMENT
Reassign Cases and Identify New Case Owner – Before user can be closed, the
supervisor must reassign all cases to an active user
(e.g. another
caseworker or a Supervisor)
. Enter name of the new case owner.
End Date: Enter the End Date
(effective date that the account will be suspended)
.
Defaults to current date.
Cases Reassigned (
completed by Security Officer)
– Check appropriate box.
Reopen Previous Positions – Check appropriate box.
REPORTING
Check appropriate box for the security group(s) to which the reactivated user needs access. A user
can be given access to multiple groups. Contact the CMIPS II Help Desk to request that this user be
reactivated in the Reporting area.
Security Officer/Administrator Signature – Enter Security Officer/Administrator’s signature.
Date – Enter date Security Officer/Administrator signed form.
SOC 883 (8/13) PAGE 3
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