DHS 785T Information & Instructions

Individual User Profile CAF Child Support Program (CSP) Screens This is a temporary form for use by Self-Sufficiency and Child Welfare. By June 30, 2005, this form must be completed for each Self-Sufficiency and Child Welfare employee and signed by the employee’s manager. This form should be retained locally.

Individual User Information Name: First M.I. Last User ID Number Effective Date

Email Address Phone Extension Position/Title ( ) Work Address City State Zip

Self-Sufficiency All Self-Sufficiency Staff (full access)

Child Welfare Central Office Children’s Benefit Unit (full access+) Central Office Adoptions (full access) Federal Revenue Specialist (full access) Social Service Specialist I or II (full access) Other by Special Request* (full access) Line Casework Supervisor (of one of the above) (full access) Other (access limited to four CSP screens)

*Full access has been granted to some Child Welfare staff who are not FRS’, SSI’s or II’s, Central Office Adoptions staff or Central Office Children’s Benefit Unit staff. Full access is granted to these staff when the access is needed in order for them to carry out their CPS-related and eligibility–related job duties and when the staff person’s manager submits a written request to Central Office (Amy Sevdy) for additional access.

Signature Supervisor/Manager (Print Name) Supervisor/Manager Signature Date

Phone Number Extension Fax Number ( ) ( )

DHS 0785T (4/05) DHS 785T Information & Instructions

DHS 785T Information

 This is a required form that must be completed for every Self-Sufficiency and Child Welfare employee by June 30, 2005, in order to meet the terms of the Access Agreement between the Department of Human Services and the Department of Justice. This requirement applies to current employees and any other employees hired on or before June 30.

 The purpose of this form is to indicate the access to Child Support Program screens that each Self- Sufficiency and Child Welfare employee has.

 This form is not to be used to request access to Child Support Program screens. Requests for access must be made according to current procedure.

 This form is temporary and will be phased out following the June 30 deadline.

 This form should be retained locally.

 “Full access” as used in this form means access to all the Child Support Program screens available to Department of Human Services staff.

DHS 785T Instructions

 Complete section titled “Individual User Information.” For “User ID Number,” enter the worker’s RACF ID number.

 Complete either the “Self-Sufficiency” or “Child Welfare” section, whichever is appropriate.

a. If the User is a Self-Sufficiency staff member, mark the box under “Self-Sufficiency” titled “All Self-Sufficiency Staff.” (DHS staff who should mark this box include the following: Oregon Health Plan workers, Overpayment Writers, Fraud and Investigations and Hearings Representatives.)

b. If the User is a Child Welfare staff member, mark the appropriate box under “Child Welfare” according to job duty. Mark only one box in this section.

 Complete section titled “Signature.” The signature of the User’s manager is required.

DHS 0785T (4/05)