User Account Checklist

* = required field
Select Action:*
Open a new account



Please provide the name of the user being updated and then provide just the updated information below. All other fields can be left blank.
Full Name
First:*
Middle Initial:
Last:*
Title:*
IMPORTANT: Please choose the role(s) that best represent you. This will be used to set your permissions within the website and data entry application.
Function/Role:*

(check all that apply)
Operations Team
Feasibility Site PI
Feasibility Site Investigator
Feasibility Site Administration
Feasibility Site Coordinator
Feasibility Site Pharmacist
Other
Personnel ID:*

(This is a 4-digit ID that will identify all personnel for certification purposes.)
Partnership:*
Home Site:*
Work Address
Name of Institution:*
Street 1:*
Street 2:
City:*
State:*
Zip Code:*
Mailing Address (if different from above)
Street 1
Street 2
City
State
Zip Code
Work Phone:*
Pager Number
Fax Number
Work Email:*
Does this user have a user login for any of the following networks/projects:*
AsthmaNet, DMS_PM, IAH, ICARE, IDEA, MSPI, ORBEX, PAMIPA, PARK, SARP, SMILE, T1DAPC, TRAIN?
Yes
No
Additional Instructions/Requests
  
Please enter the name or username of the individual for whom you would like to request changes. You may search on partial names. Press the search button and then select the Edit/Delete link next to the correct user.
First Name:
Username:
Last Name:
Effective Date: