Redcap User Agreement And Account Application/Modification Survey

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REDCap New User Account Form or for modification of an existing account.

If required fields are left blank the process of creating an account will be delayed!

Your primary contact email MUST be unique to you.

Thank you!

Do not hesitate to reach out if you have any questions.

The REDCap Email Account - redcap@health.nv.gov

The SER Email Account - ser@health.nv.gov

https://dpbhrdc.nv.gov/redcap/index.php

Jesse Wellman Biostatistician II jessewellman@dhhs.nv.gov

Nevada Department of Health and Human Services

4126 Technology Way |Carson City, NV 89706 T: (775) 684-4112 - Telecommute (775) 560-5582

www.dhhs.nv.gov | Send data requests to data@dhhs.nv.gov

Helping People. It's who we are and what we do.

The information entered here is for a new REDCap account or an EXISTING person's REDCap account modification? (not in regard to the facility/organization)

This is a new REDCap account for me.

This is a modification to an existing REDCap account I have.

This is a reactivation of an existing REDCap account that was previously suspended.

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User Account 'username':

Is this user's account representing a facility, organization, agency or entity using REDCap for the first time?

This is a newly reporting facility

This is a facility that has used REDCap before.

This account is not related to a healthcare facility.

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NOTICE of USER AGREEMENT - TERMS OF USE

This agreement authorizes use of the State of Nevada's REDCap reporting platform. As an State of Nevada Redcap User you are certifying by signing below that you will only use the system for its intended purpose, use only your organization's authorized computer terminals, maintain the secrecy of your password, log off when the task is completed, maintain all PII confidentiality, and notify the State of Nevada Sentinel Events Registry at ser@health.nv.gov when the account is no longer needed so it can be de-activated.

First Name

* must provide value

Name Last

* must provide value

Nickname or how addressed.

What is your job role?

Primary phone number i.e. (7751234567)

* must provide value

Does your primary phone number require an extension?

Yes

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Primary phone number extension

Alternative phone number i.e. (7751234567)

Does your alternative phone number require an extension?

Yes

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Primary Email (must be unique to you) (your name and/or initials must be in the email address)

* must provide value

Secondary Email

What is your expected role using the REDCap platform?

What program(s)/project(s) do you need to access?

What department or group in your organization do you represent? If not applicable, leave blank.

Does your organization have a website? If so, please enter that here.

If you need to look up your facility's HCQC license information, this is the URL

https://nvdpbh.aithent.com/login.aspx.

a) Select business unit (Healthcare)

b) In the lower left inside the white background box select > LICENSE VERIFICATION, FACILITY LOCATOR & INSPECTION REPORTS (personnel/health facility/laboratory/kitchen pool & spa) Click Here

c) In the text field for 'Last Name' put your facilities DBA name.

d) Use wildcards like '%' if the name does not appear with the first query.

Select 'Yes' if you would like screenshots of how to look up your facility's Health Care Quality Compliance Bureau number.

Yes

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How to look up your facilities HCQC license number image 1.

How to look up your facilities HCQC license number image 2.

How to look up your facilities HCQC license number image 3.

How many reporting entities will you represent for this account? (minimum 1, maximum 10)

01 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

01 Is your organization a 'Healthcare Facility'?

Yes

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01 Your organizations State of Nevada, Health Care Quality Compliance license type? Or if you represent a government entity or a community-support non-profit entity.

* must provide value

01 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

01 Facility phone number i.e. (7751234567) at this location.

* must provide value

01 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

01 Your organization's physical city of operation.

01 If your facility is physically located in a city/town not listed, please enter it here.

01 State (Two character postal abbreviation, i.e. NV)

02 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

02 Is your organization a 'Healthcare Facility'?

Yes

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02 Your organizations State of Nevada, Health Care Quality Compliance license type? Or if you represent a government entity or a community-support non-profit entity.

* must provide value

02 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

02 Facility phone number i.e. (7751234567) at this location.

* must provide value

02 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

03 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

03 Is your organization a 'Healthcare Facility'?

Yes

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03 Your organizations State of Nevada, Health Care Quality Compliance license type? (If you believe that your facility license type is not listed please contact ser@heatlh.nv.gov to discuss)

* must provide value

03 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

03 Facility phone number i.e. (7751234567) at this location.

* must provide value

03 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

04 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

04 Is your organization a 'Healthcare Facility'?

Yes

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04 Your organizations State of Nevada, Health Care Quality Compliance license type? (If you believe that your facility license type is not listed please contact ser@heatlh.nv.gov to discuss)

* must provide value

04 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

04 Facility phone number i.e. (7751234567) at this location.

* must provide value

04 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

05 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

05 Is your organization a 'Healthcare Facility'?

Yes

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05 Your organizations State of Nevada, Health Care Quality Compliance license type? Or if you represent a government entity or a community-support non-profit entity.

* must provide value

05 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

05 Facility phone number i.e. (7751234567) at this location.

* must provide value

05 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

06 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

06 Is your organization a 'Healthcare Facility'?

Yes

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06 Your organizations State of Nevada, Health Care Quality Compliance license type? Or if you represent a government entity or a community-support non-profit entity.

* must provide value

06 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

06 Facility phone number i.e. (7751234567) at this location.

* must provide value

06 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

07 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

07 Is your organization a 'Healthcare Facility'?

Yes

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07 Your organizations State of Nevada, Health Care Quality Compliance license type? Or if you represent a government entity or a community-support non-profit entity.

* must provide value

07 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

07 Facility phone number i.e. (7751234567) at this location.

* must provide value

07 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

08 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

08 Is your organization a 'Healthcare Facility'?

Yes

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08 Your organizations State of Nevada, Health Care Quality Compliance license type? Or if you represent a government entity or a community-support non-profit entity.

* must provide value

08 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

08 Facility phone number i.e. (7751234567) at this location.

* must provide value

08 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

09 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

09 Is your organization a 'Healthcare Facility'?

Yes

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09 Your organizations State of Nevada, Health Care Quality Compliance license type? Or if you represent a government entity or a community-support non-profit entity.

* must provide value

09 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

09 Facility phone number i.e. (7751234567) at this location.

* must provide value

09 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

10 Your organizations State of Nevada, Health Care Quality Compliance license number (for healthcare facilities, childcare facilities, or emergency medical service organizations) or put 'gov', or 'public service'?

10 Is your organization a 'Healthcare Facility'?

Yes

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10 Your organizations State of Nevada, Health Care Quality Compliance license type? (If you believe that your facility license type is not listed please contact ser@heatlh.nv.gov to discuss)

* must provide value

10 Your organizations public name (dba or the name on the sign in front of the business)

* must provide value

10 Facility phone number i.e. (7751234567) at this location.

* must provide value

10 Zip Code (simple 5 digit i.e.89000, no extension)

* must provide value

Are you the 'owner - operator' of this facility?

Yes

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Who in your organization is your supervisor or boss and authorizes your need for a REDCap account? (If owner - operator put your own name)

* must provide value

Authorizing supervisor or boss person's email (If owner - operator put your own email)

* must provide value

Authorizing supervisor or boss person's phone number (7021234567) (If owner - operator put your own phone number)

* must provide value

Does your authorizing person's phone number require an extension?

Yes

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Authorizing person's phone number extension. (number)

Authorizing person's cell or mobile or alternate phone (must not need an extension) number (7021234567)

Authorizing person's FAX number (7023456789)

Do you have any staff changes to report?

Yes

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List all past staff and if possible, their email and REDCap usernames, so that those accounts can be 'de-activated'.

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Welcome to REDCAP!

TERMS AND CONDITIONS subject to change without notice.

Your organization has requested that you have access to projects associated with your organization. As a State of Nevada REDCap User (herein REDCap User), you will be required to complete the attached REDCap User Form.
REDCap Users must always keep their contact information current. This includes a valid email and a valid phone number so the State of Nevada can notify the users of changes, outages, or potential security breaches. If any REDCap User email is returned as invalid, expired, or notifying us of the REDCap User's termination from their organization, we will immediately suspend the account.

If your account is suspended, you will have to contact the State of Nevada Redcap Administrators at redcap@helath.nv.gov, or 775-684-4112 or if telecommuting is in effect 775-560-5582.

As a REDCap User, you are required to protect of Personally Identifying Information (PII). REDCap Users must never share passwords with other users or persons. This includes members of your organizations, State of Nevada Employees, or any other persons. Any and all use of the information entered or stored in the State of Nevada's REDCap platform for use by your organization for business purposes.

The email provided must be unique to the REDCap user. Duplicate emails in the user community will be suspended until the users are confirmed and the replicate email is resolved . Is there is a need for a generic email for reporting, this can be accommodated by using a secondary email.

REDCap Users are prevented from using the last five previous passwords . User are required to change their passwords every ninety (90) days . REDCap User accounts will be locked after three (3) unsuccessful attempts to log into the system. The account will automatically unlock after 30 minutes of inactivity.

REDCap Users will never attempt to bypass security features to gain access to unauthorized information.
REDCap Users are issued a username and a temporary password when the REDCap User Form is completed. When the REDCap Users log in the first time, they will be forced to change their password to a new one. The new REDCap User password must be protected and remain secret.

Passwords are not to be shared between staff.

REDCap users must log out of REDCap when not at their terminal or workstation. It is the REDCap User's responsible to ensure there is no unauthorized access to the REDCap database, projects, or surveys using their credentials. Audit logs are periodically monitored by the State of Nevada Information Technology team to review REDCap Users' activity.
If you do not log in to the REDCap platform for longer than 180 days, your account is automatically suspended.

Version 202202a

Your signature (mark exclusive to you) indicates you have completed this form, have read the User Agreement, and that you will make every effort to abide by the requirements.

* must provide value

Add signature

Assigned REDCap username

Who created account

When was account created

Record has been processed

Yes

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When was record processed.

Who processed record?

Comment regarding user completing sign up form, and creating a pw and logging in.

Comments1

Comments long form

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Programs user is associated with

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Suspended reason

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