Facility Personnel Update Form

Notify the Network of important Personnel/contact information changes using this Form.

Important Note: Only update staff/positions where a change has occurred.

If staff/position remains the same, you do NOT need to submit an update.
Select Your Facility - NW16
Name of person completing this Form
Email for person completing this Form
Pending Facility Name
Pending Facility State

Pending Facility State Alaska Idaho Montana Oregon Washington
I would like to make the following changes (select all that apply):

I would like to make the following changes (select all that apply): Remove Staff Add/Update Staff
Names and Roles of any staff to REMOVE from Facility Personnel list. If you have not already done so, make sure to provide the information for the replacement (Add/Update Staff).
Staff Update 1:

Enter staff change (1) here.
This person will receive any Network communications relevant to their selected position at this facility:
1: Full Name (and Credentials if applicable)
1: Work Email
1: Phone # (Including Extension if applicable)
1: Roles (Select ALL that apply)

1: Roles (Select ALL that apply) Facility Administrator/Clinic Manager Facility Medical Director Facility Head Nurse/Nurse Manager EQRS/Facility Data Contact Facility Social Worker Disaster/Emergency Contact A Facility Dietitian Disaster/Emergency Contact B Home Coordinator Master Account Holder Transplant Coordinator Regional Contact
1: Disaster/Emergency Contact A Cell Phone
1: Disaster/Emergency Contact B Cell Phone
Update another Position (2)?

Update another Position (2)? Yes (Update 2) No - No 2
Staff Update 2:

Enter staff change (2) here.
2: Full Name (and Credentials if applicable)
2: Work Email
2: Phone # (Including Extension if applicable)
2: Roles (Select ALL that apply)

2: Roles (Select ALL that apply) Facility Administrator/Clinic Manager Facility Medical Director Facility Head Nurse/Nurse Manager EQRS/Facility Data Contact Facility Social Worker Disaster/Emergency Contact A Facility Dietitian Disaster/Emergency Contact B Home Coordinator Master Account Holder Transplant Coordinator Regional Contact
2: Disaster/Emergency Contact A Cell Phone
2: Disaster/Emergency Contact B Cell Phone
Update another Position (3)?

Update another Position (3)? Yes - Update 3 No - No 3
Staff Update 3:

Enter staff change (3) here.
3: Full Name (and Credentials if applicable)
3: Work Email
3: Phone # (Including Extension if applicable)
3: Roles (Select ALL that apply)

3: Roles (Select ALL that apply) Facility Administrator/Clinic Manager Facility Medical Director Facility Head Nurse/Nurse Manager EQRS/Facility Data Contact Facility Social Worker Disaster/Emergency Contact A Facility Dietitian Disaster/Emergency Contact B Home Coordinator Master Account Holder Transplant Coordinator Regional Contact
3: Disaster/Emergency Contact A Cell Phone
3: Disaster/Emergency Contact B Cell Phone
Update another Position (4)?

Update another Position (4)? Yes - Update 4 No - No 4
Staff Update 4:

Enter staff change (4) here.
4: Full Name (and Credentials if applicable)
4: Work Email
4: Phone # (Including Extension if applicable)
4: Roles (Select ALL that apply)

4: Roles (Select ALL that apply) Facility Administrator/Clinic Manager Facility Medical Director Facility Head Nurse/Nurse Manager EQRS/Facility Data Contact Facility Social Worker Disaster/Emergency Contact A Facility Dietitian Disaster/Emergency Contact B Home Coordinator Master Account Holder Transplant Coordinator Regional Contact
4: Disaster/Emergency Contact A Cell Phone
4: Disaster/Emergency Contact B Cell Phone
Update another Position (5)?

Update another Position (5)? Yes - Update 5 No - No 5
Staff Update 5:

Enter staff change (5) here.
5: Full Name (and Credentials if applicable)
5: Work Email
5: Phone # (Including Extension if applicable)
5: Roles (Select ALL that apply)

5: Roles (Select ALL that apply) Facility Administrator/Clinic Manager Facility Medical Director Facility Head Nurse/Nurse Manager EQRS/Facility Data Contact Facility Social Worker Disaster/Emergency Contact A Facility Dietitian Disaster/Emergency Contact B Home Coordinator Master Account Holder Transplant Coordinator Regional Contact
5: Disaster/Emergency Contact A Cell Phone
5: Disaster/Emergency Contact B Cell Phone
If you need to update more than 5 staff positions, please submit a second online form.
Date of Update Date of Update / MM / DD YYYY

Facility Personnel Update Form

Facility Personnel Update Form

Important Note: Only update staff/positions where a change has occurred.

Staff Update 1:

Staff Update 2:

Staff Update 3:

Staff Update 4:

Staff Update 5:

If you need to update more than 5 staff positions, please submit a second online form.