PRM SYSTEM (REDCap) USER ACCESS FORM
Please complete all fields of this form to gain access to the REDCap PRM system.Please send completed forms electronically to ACI PRM Team, . If you require further information and need assistance in completing this form then please email us at
Facility/Practice Name
Facility /Practice generic email to be used*
Data Access Group Name (DAG)** / TO BE PROVIDED BY ACI
Street Address of facility/practice
Postcode / Local Health District
(if applicable)
APPLICANT DETAILS
Surname / Name
Contact number
Position
Your Email address
Access Start Date / DD/MM/YYYY / Expiry Date / DD/MM/YY
Level of Access Required
(tick one) / Local Super User Local Project User
Note;
1. Forms that do not contain all required information may be rejected.
2. **DAG: ACI will provide you with this name to be added to the form
3. *Generic Email: Must be unique to the site not a personal email this is for purposes of accessing the reporting portal
Contractor/Vendor Requesting Access
I accept full responsibility for the computer access that I may be given, and I agree not to disclose any information that may assist any person to gain access to HealthShare NSW computer systems. Such information is private and confidential and is bound by the by-laws of the NSW Health Policy Directives and Legislation. If you sign this you are agreeing that you have read, understood and will abide by the following policies:
- PD2009_076 - Use & Mgmt of Comms System (
- PD2013_033 –Electronic Information Security (
- PD2012_018 –Code of Conduct (
*Signature: / Date:
Authorised Signatory: To be completed by the authorised manager responsible for the Employee.
I authorise the applicant to be given access to the REDCap PRM system as indicated on this form. I undertake to inform ACI NSW if the applicant no longer requires access or the applicant leaves the employ/contract of the stated Clinic/PracticeCompany;
*Name: / *Position
*Signature: / Date: