EvaluationWeb: Delete Account Form Request to Delete Account from Minnesota EvaluationWeb INSTRUCTIONS: This form is to be completed by the supervisor to remove a user’s access to Minnesota EvaluationWeb. This form should be completed as soon as the supervisor is aware that an employee will no longer require access to EvaluationWeb, whether due to a change in responsibilities or that the employee is leaving or has left the agency. The form MUST be completed within one business day of the change in responsibility or employment status taking effect. Once the form is completed, forward the original signed form to the Minnesota Department of Health’s (MDH) EvaluationWeb Data Coordinator. Keep a copy of this form on file at your agency. Mail request to: Or Fax request to: Minnesota Department of Health STD and HIV Section – Attn: Tina Klein 625 Robert Street North, P.O. Box 64975 St. Paul, Minnesota 55164‐0975 Confidential Fax: 651‐201‐4040 Agency Name: Date Requested: Remove the following user’s access to Minnesota EvaluationWeb: Employee Full Legal Name: Effective Date of Removal: Supervisor’s Name: Supervisor’s Signature: Supervisor’s Phone: MDH Internal Use Only: EvaluationWeb Data Project Coordinator: Approved Forward to EvaluationWeb Administrator for Implementation: Username: Denied
System Removal Completion:
Effective Date: Effective Date: Effective Date:
EvaluationWeb Delete Account Form – V.1
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