This document is a request form for an information services report. It asks for the requestor's information including name, date, department, contact details, and date needed. It also asks for details about the report such as the frequency, purpose, fields to include, selection criteria, sorting preferences, and output file format. The form provides space for information services to track the request including assigning it, expected completion date, report name, and testing and production dates.

1. Information Services
Hospital Name/Image
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Requestor Information
Name:
!Date Requested:
Department:
!Date Needed:
Telephone/Ext:
!Email:
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Run
Frequency
One Time Daily Weekly Monthly Quarterly Yearly
Describe the purpose of this report:
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List all the fields that the report should include (example: Name, Address, Account Number,
etc):
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2.
3.
4.
5.
6.
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14.
15.
Define the selection criteria for the report (example: All patient visits between 1/1/12 –
1/1/14 for ER):
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If you would like the report sorted, list preferred sorting and indicate ascending or
descending order:
1.
2.
3.
4.
Ascending:
Descending:
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2. Information Services
Hospital Name/Image
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Output File Format: Labels:
MS Excel:
Delimited Text: Indicate
Delimiter:______
Printed Report:
Other:
__________________________
*****For Information Services Use Only*****
Assigned To:
Expected Comp Date:
Report Name:
Date Received:
Tested By:
Tested Date:
Date moved to Prod:
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