Common Contracts

OCHIDS Data System User Agreement

System User Agreement • August 8th, 2018

• Contract Type
  System User Agreement
• Filed
  August 8th, 2018

Name: Agency Name: Agency Street Address: Agency City: Agency ZIP: Work Email Address: Job Title: Date of Hire: OPIN-ID: Work Phone Number: ext. Gender: ☐Male ☐Female Date of Birth: Highest Completed Education: Race: ☐ American Indian/Alaskan Native ☐ Asian ☐ Black/African American☐ Native Hawaiian/Pacific Islander ☐White Ethnicity:Select One Additional Language Proficiencies (List All): ☐Registered Nurse – License Number: ☐Licensed Social Worker – License Number: ☐Certified Community Health Worker – Certification Number: ☐Other/Non-Licensed Home Visitor Credential• Issue Date: • Expiration date: Supervisor Credential• Issue Date: • Expiration date: Certified Community Health Worker• Issue Date: • Expiration date: Other Credential• Issue Date: • Expiration date: Program: Select One Model: Select One County: Role Requested: Select One Program: Select One Model: Select One County: Role Requested:Select One Program: Select One Model: Select One County: Role Requested:Select One Program: S