This form requests the information needed to set up your project or task as completely and efficiently as possible. Note that project/task names are used to track the task. Send this form to Phillip Stewart and Fred Hargrove ((Vanderbilt Pharmaceutical Services, B 101 VUH, 2-2374) via an email attachmentwhen completed. Call or email Phillip or Fred with any questions about the setup process or the items on this form.
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1. BASIC INFORMATION
Requestor: / name, (phone) / Request Date:Project Manager:
(if different from Requestor) / name, (phone) / Date Project to be completed:
Project Name: / Project Type:
/ choose oneNoneHEDHMMWiz/HEOOther
Priority Group: / choose oneLowMediumHighOther / Elevate Pillar: / choose oneFinanceGrowthPeopleQualityService
Current Phase: / choose oneEvaluationDevelopmentPre-ImplementationImplementationSupport OnlyPending ApprovalTBD / unknown
2. PROJECT DESCRIPTION
Description
Provide a brief overview of the project here (no more than 255 characters)
Keywords
List project-related terms and alternate names by which the project may be known
Cost – Impact – QA
List project-related information known or projected, safety issues, response to med error or prevention, etc
3. RESOURCES
Please list below the persons who should be involved with the project/task as resources, and/or who mayneed access to the project web site (larger projects). All affected parties listed below should be in agreement on the intent and scope of the project. Indicate the roles/permissions needed with an X in the appropriate column.(In order to have access to Project Server and the project web site for larger projects, a VUNet ID is required while logging into the Vanderbilt domain locally or via VPN.The project information can be viewed once project members are setup at )
Project/Task Members / WEB SITERIGHTS*(for project documentation web site; choose one)
First Name / Last Name / Reader / Contributor / Project Mgr
John / Doe / X
*PROJECT WEB SITERIGHTS: Reader= view all information but not edit or upload documents & list items; Contributor = Readerplus edit and upload documents & list items; Project Manager = Contributor plusmanageproject web site.
PROJECT CUSTOMIZATION
All projects and possible project web sites will have project overview andregular review/status updates.
AGREEMENT
By submitting this project/task request, the Project Manager/Designee agrees that, in accordance with HIPAA regulations and Vanderbilt policy, no Patient Protected Health Information (PPHI)will be posted in any project plan or project web site. PPHI includes patient demographics, medical record numbers, case numbers, and any piece of information that could be tied to a patient. The Project Manager/Designee will inform all project members and site users of this policy, and will monitor the plan and web site contents to ensure that such information is not made available.
I AgreeProject Manager/Designee Name: Date: