HMMS User Profile Amendment : HMMS Site Only

1
Name of HMMS site* This field is required.Please choose which site you are requesting from
Please Select
Please Select
Connolly Hospital Blanchardstown
Children's Health Ireland
Merlin Park University Hospital
Phoenix Pharmacy
Rotunda Hospital
South Infirmary Victoria University Hospital
St. Vincent's University Hospital
Tallaght University Hospital
University Hospital Galway
CHI Crumlin
2
Name of Requestor* This field is required.Please provide your full name
First Name
Last Name
3
Email of Requestor* This field is required.Email Contact 1
example@example.com
4
Email of HMMS User* This field is required.(To send the HMMS User their username & password)
example@example.com
5
Line Manager / Chief Pharmacist Email* This field is required.Email Contact 2 (User Access must be approved by Line Manager/ Chief Pharmacist)
example@example.com
6
Phone Number* This field is required.
Area Code
Phone Number
7
What is the HMMS Username?Please submit your HMMS Username that you use to log into HMMS
8
Current HMMS User ProfilePlease select HMMS User Profile that describes your current HMMS role
Please Select
Please Select
System Manager
Chief Pharmacist
Pharmacist
Pharmacy Technician
Procurement
Pharmacy Aide
Pharmacy Admin
Student
Research
Finance
Finance (with Invoice Reconcilliation)
Stock Locator
9
Reason for User Amendment* This field is required.Detail why the user profile is to be amended e.g. User has ceased deployment, Maternity Leave, Change of Job Role
Please Select
Please Select
Ceased Employment
Change of Job Role
Maternity leave
Error in Original Request (Please detail in Additional Information)
10
New HMMS User ProfilePlease select your new HMMS User Profile
Please Select
Please Select
System Manager
Chief Pharmacist
Pharmacist
Pharmacy Technician
Procurement
Pharmacy Aide
Pharmacy Admin
Student
Research
Finance
Finance (with Invoice Reconcilliation)
Stock Locator
11
User Profile DetailsPlease fill in the details of User Profile
12
Approval for HMMS User Profile* This field is required.The HMMS User Profile must be agreed with your line manager
Name of Line Manager
Role of Line Manager
Please Select
Please Select
Yes
No
Disclaimer: My Line Manager / Chief Pharmacist are aware and they have approved my user role
13
Additional informationPlease input any additional information or comments to support your request
Huge
Large
Normal
Small
Ok
Ok
14
File AttachmentSubmit documents as required to supplement request
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
Confirmation Email ConsentA confirmation email will be sent to you once your Jotform is submitted. Please tick the box below to confirm consent
Agree
Should be Empty: