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Request/Modify Database Access
For Healthcare Providers
/
Request/Modify Database Access
Please enable JavaScript in your browser to complete this form.
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Step
1
of 2
Request Type
*
New
Modify
Reactivate
Remove/Deactivate
Name Change
Specify the modification you would like to request:
Database
*
WCCHN Interprovincial and Referral Database
Centripetus_STS Congenital Heart Surgery Database (Society of Thoracic Surgeons)
Centripetus_STS CHSD Anesthesia Section (Society of Thoracic Surgeons)
Centripetus_ACC IMPACT (American College of Cardiology's Improving Pediatric and Adult Congenital Treatments)
Centripetus_PAC3 (Pediatric Acute Care Cardiology Collaborative)
Centripetus_PC4 (Pediatric Cardiac Critical Care Consortium)
Tableau_WCCHN Administrative Data Dashboards
WCCHN Headquarters Account
Network Username (the username you use to log into your health authority's computers)
DOB: MMM/DD only; no year
Previous Full Name
New Full Name
Request Date
Effective Date
Expiration Date (if applicable)
User Demographics
Title
Name
*
First
Last
Business Phone
Extension
Email
*
WCCHN Home Site:
*
Alberta Children's Hospital, Calgary
BC Children's Hospital, Vancouver
Children's Hospital HSC, Winnipeg
Jim Pattison Children's Hospital, Saskatoon
Stollery Children's Hospital, Edmonton
I require access to the following additional sites:
Alberta Children's Hospital, Calgary
BC Children's Hospital, Vancouver
Children's Hospital HSC, Winnipeg
Jim Pattison Children's Hospital, Saskatoon
Stollery Children's Hospital, Edmonton
Position Name or Role Description
*
Employer Department/Unit
Name of Clinical Manager/Director
Security Group Assignment - WCCHN
Cardiologist/Clinician with referral creation
Nurse/Clinician without referral creation
Admin
Research/View Only
Other
Security Group, Other:
Security Group Assignment - STS CHSD
Surgeon
Anesthetist
Perfusionist
Admin
Research/View Only
Other
Security Group, Other:
Security Group Assignment - ACC IMPACT
Cardiologist
Nurse
Admin
Research/View Only
Other
Security Group, Other:
Security Group Assignment - PAC3
Cardiologist
Nurse
Admin
Research/View Only
Other
Security Group, Other:
Name of user with same or similar access
Name of person completing this form
*
Email
*
Information Privacy & IT Security Awareness Training
Before access to any WCCHN managed database or quality registry can be granted, you are required to complete an Information Privacy & IT Security Awareness training module.
You can complete the Privacy Training Module at any time. It takes about ten minutes. You do not need to have it completed before submitting this form.
At the end of the Privacy Training Module, you will find the
Confidentiality and User Agreement Form (CUA)
. Please download the form, complete it, and send to WCCHNAdmin@ahs.ca. Once your CUA is received, access will be provisioned.
Information Privacy and Security Awareness Training with Confidentiality and User Agreement Form
https://ahamms01.https.internapcdn.net/ahamms01/Content/AHS_Website/Information_For/if-hp-ip-privacy-it-security/index.html
For WCCHN Office Use Only
Leave this section blank and click next at the bottom of the screen
Status
Pending
AHS Information Privacy and IT Security Awareness Training requested
Confidentiality/User Agreement received and filed
Added to email distribution list
Account created
Credential and Training email sent
Complete
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Our Organization
About WCCHN
Meet Our Team
Our History
By The Numbers
Giving
Our Partner Hospitals
Alberta Children’s Hospital
BC Children’s Hospital
Children’s Hospital, HSC
Jim Pattison Children’s Hospital
Stollery Children’s Hospital
For Parents & Families
Your Child’s Surgery
Getting Prepared
At the Stollery
At BC Children’s
Financial Planning
Packing Guide
Knowledge
Fetal Cardiology
Surgery & Treatments
Living with CHD
Developmental Care
Transitioning to Adult Care
Grief & Bereavement
View All Resources
Community
Finding Support in Your Province
Caregiver’s Corner
Family & Patient Stories
The Story Corner
Camps for Fontans
Thank a Staff Member
BoostUp Pitch Competition
For Healthcare Providers
Contact
HQ Login