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
Date
Security Group
CORE
SYSTEM ADMIN
HEALTH BENEFITS MANAGER
Y/N
Reassign Cases and Identify New Case Owner (Name)
End Date:
