2. Please fill out this form at least two weeks (10 business days) before changes are needed.  Please save a copy for your records.

4. Supervisor Requesting
5. Date Requested
   Date Requested
6. Date Needed*
   Date Needed
8. User First and Last Name*

   Please spell names correctly. Thank you.

9. Employee Status:*
   -- Select One --New EmployeeContract WorkerPosition/Title Change OR Moving OfficesNo longer employed
11. New Job Title
    If changing positions. No acronyms.
12. Current Phone Number*
    Input "N/A" if new user
13. New Phone Number*
15. New Office Number
    Room number
16. Supervisor Phone Number*
17. Division*
    -- Select One --AdministrationAdoptionAdult MedicaidAdult ServicesChild supportCPS In-Home ServicesCPS IntakeCPS InvestigationsExecutiveF&C MedicaidFamily Support ServicesFood & NutritionFoster CareIncome Maint/Quality ControlLegalLIEAPStaff DevelopmentWork First/Daycare/WFFA

    Select DSS group

19. New Computer Name*

    *Usually a label located on the tower, ex: D2DSSADM601

23. Check Required Distribution Groups

    1. NONE
    2. 8194
    3. Administration
    4. Adoptions
    5. Adult Intake-NEMT
    6. Adult Medicaid
    7. Adult Services
    8. Case Number
    9. Child Care (Work First included)
    10. Child Care (Work First n/included)
    11. Child Support
    12. Child Support Enforcement
    13. Child Support Establishment
    14. Children's Services
    15. Children's Social Workers
    16. CPS Employees
    17. CPS In-Home Services
    18. CPS Investigations
    19. CPS Intake
    20. DSS All Staff
    21. DSS Service Supervisors
    22. Exec Management Team
    23. Family Support Services
    24. Family-Children Medicaid
    25. Food Assistance
    26. Forms
    27. Foster Care
    28. Guardianship Team
    29. Income Maintenance
    30. Income Maintenance Quality Control
    31. Income Maintenance Supervisors
    32. Legal
    33. Management Team
    34. Placement
    35. Prep Team
    36. Program Integrity
    37. Services Employees
    38. Services Supervisors
    39. WFES
    40. WFFA
    41. Work First
24. Check Calendar Access

    1. NONE
    2. Administration
    3. Adoptions
    4. Adult Medicaid
    5. Adult Services
    6. Child Support
    7. CPS In-Home Services
    8. CPS Intake
    9. CPS Investigations
    10. Executive Management
    11. Family-Children's Medicaid
    12. Family Support Services
    13. Food Assistance
    14. Foster Care
    15. Income Maintenance Quality Control
    16. Interpreter
    17. Legal
    18. Work First/Child Care
    19. 1st Floor Work First Conference Rm
    20. 2nd Floor Conference Rm
26. Check Restricted Programs Access

    1. NONE
    2. Collection Log
    3. CPS Tracker
    4. Master Client Index Database
    5. Transportation Database
    6. Child Care Database
    7. WFFA Caselog Database
    8. DSS Document Library
27. Check Shared Drive Access*

    1. NONE
    2. G Drive (FNS)
    3. I Drive (File Room)
    4. I Drive (FoodStampLog)
    5. J Drive (Fraud)
    6. K Drive (ChildSupport)
    7. L Drive (Legal)
    8. L Drive (CPSSupervisors)
    9. M Drive (AdultMedicaid)
    10. N Drive (EmployeeTracker)
    11. O Drive (FC&AdultMedicaidLogs)
    12. P Drive (Prevention)
    13. P Drive (Personnel)
    14. Q Drive (CPS Resources)
    15. R Drive (FCMedicaid)
    16. S Drive (Services Share)
    17. T Drive (CPSReports)
    18. T Drive (Transportation)
    19. U Drive (Supervisor_Lead)
    20. V Drive (Adult Services)
    21. W Drive (WorkFirst-ChildCare)
    22. X Drive (Foster Care & Adoptions)
    23. Y Drive (Administration)
    24. Z Drive (Mail Files)

    If you do not see the needed drive(s) above, please explain what you need in the "Other needs" section.
29. Other needs:
    Ex. NC Fast, NCIR, State Sessions, etc.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field