Tennessee Region RCCare User Access Request Form
Name of Requester
*
First Name
Last Name
Email of Requester
*
example@example.com
Type of Account Request
*
Please Select
New
Modify
Remove
Sandbox
Name of User needing RCCare access
*
First Name
Last Name
Primary phone of user
*
Please enter a valid phone number.
Timezone of User
*
Please Select
Eastern
Central
Volunteer Connection SSO Email
*
example@example.com
Volunteer Connection Member #
*
Chapter Name
*
Please Select
NorthEast
East
SouthEast
Heart of Tennessee
Nashville Area
Tennessee River
MidWest
MidSouth
Background Check
*
Please Select
Clear
Not Completed
GAP
*
Please Select
RES/DAT/SA
RES/DAT/SV
RES/DAT/MN
REC/CRP/SA
REC/CRP/SV
REC/GEN/SA
REC/GEN/SV
IDC/DHS/SA
IDC/DHS/SV
IDC/DMH/SA
IDC/DMH/SV
IDC/DSC/SA
IDC/DSC/SV
N/A (only for RDO, Monitor, Compliance, Acct Auth)
RCCare User Role
*
Please Select
Casework Supervisor - Intake
Casework
Compliance Reviewer
Event Reviewer
ID/Address Document Reviewer
IDC
Intake Worker
Monitor/Reporting (Read Only)
RDO Exception Approver
Regional Event Administrator
Account Authorizer
CANCEL ACCESS TO RCCARE
Client Care Program Overview Completed On
*
-
Month
-
Day
Year
Date
Detailed Damage Assessment for DAT Operations Completed On
*
-
Month
-
Day
Year
Date
Client Care Program: Disaster Client Intake Completed On
*
-
Month
-
Day
Year
Date
Providing and Documenting Individual Disaster Care Service with RC Care Completed On
*
-
Month
-
Day
Year
Date
Client Care Program: Disaster Event Management Completed On
*
-
Month
-
Day
Year
Date
Client Care Program: Conducting Follow Up Completed On
*
-
Month
-
Day
Year
Date
Client Care Program: Recovery Planning Completed On
*
-
Month
-
Day
Year
Date
Shelter Resident Transition with RC Care Completed On
*
-
Month
-
Day
Year
Date
Client Care Program: Providing Referrals Completed On
*
-
Month
-
Day
Year
Date
Client Care Program: Compliance Completed On
*
-
Month
-
Day
Year
Date
Client Care Program: Event Confirmation
*
-
Month
-
Day
Year
Date
Document Review Class Completed On
*
-
Month
-
Day
Year
Date
Reason for the change (Required for Remove Access)
*
As part of the Fiscal Control process, I (The Requester) confirm that the information submitted on this form is accurate and that I have verified the training courses have been completed prior to form submission.
Submit
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