Free Wisconsin Incident Tracking System Web Access Request - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20483 (02/2009)

STATE OF WISCONSIN

WISCONSIN INCIDENT TRACKING SYSTEM (WITS) WEB ACCESS REQUEST
Completion of this form is required in order to have access to the WITS system. INSTRUCTIONS: 1. Users must first have a WAMS ID--http://on.wisconsin.gov--Use this URL to logon to WAMS home page and click on selfregistration link to create a new account OR use the other options on this page for subsequent account maintenance. 2. Once WITS users have a WAMS ID, they must complete this form, sign the form, have their supervisors sign the form, and then fax the form to DHS, Attn: Karl Schlenker, FAX ­ 608-267-3203, Telephone ­ 608-266-2537. Your Name (Last, First, MI) User ID from WAMS Name ­ Employing Agency (do not abbreviate) Type of Agency County Dept. of Human Services, Social Services, Health, etc. County Aging Unit Aging and Disability Resource Center Nongovernmental agency contracted to one of the above Other (describe: Your Telephone Number County(ies) for Which You Will be Reporting Date Account Needed

WITS access needed to file reports on incidents involving:
(select one) Elder adults-at-risk only (those age 60+) Adults-at-risk only (those age 18-59) Adults-at-risk in both age groups (18 and over)

AUTHORIZING SIGNATURES If your employer is a COUNTY AGENCY, COUNTY AGING UNIT, or ADRC, complete the following:
Name ­ Supervisor E-mail Address ­ Supervisor SIGNATURE ­ Supervisor Date Signed Telephone Number - Supervisor

If your employer is a NONGOVERNMENTAL CONTRACT AGENCY, complete the following:
Name ­ County Agency Holding the Contract Name ­ County Agency Supervisor or Contract Signer E-mail Address ­ County Supervisor SIGNATURE ­ County Agency Supervisor or Contract Signer Date Signed Telephone Number ­ County Supervisor

User of this logon and password provides access to confidential information, which must be safeguarded in accordance with Wisconsin Statutes. The User's signature on this form constitutes acceptance of responsibility for compliance with §49.32(10), §49.32(10m), §49.81, §49.83, §943.70(2), and with DHS policy (attached to new logon approvals).
SIGNATURE ­ User Date Signed