Get Chirp Individual User Agreement With Doa - State Of Indiana - Chirp In

Completing the CHIRP Individual User Agreement with the Delegation of Authority is an important step for individuals seeking access to the Children and Hoosier Immunization Registry Program. This guide will walk you through the process of filling out this agreement clearly and effectively.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the CHIRP Individual User Agreement and open it for editing.
2. Complete all required fields on both page one and two of the form. Ensure that the employee’s name, signature, and date are filled out accurately on page one.
3. Have both the employer and the Medical Officer sign and notarize page two of the form. This is crucial for validating the agreement.
4. Indicate the desired level of access for the user at the bottom of page two: Choose from view only, full access, lead results, inventory lot management, or physician/vaccinator management.
5. Return both signed pages via fax to 317-233-8827 or mail them to the designated address provided in the instructions.
6. Keep a signed copy of the form along with the notarized Delegation of Authority in the employee's personnel file.
7. If necessary, use the Remove User form to delete a User from your site after their employment ends and fax it to CHIRP within one week.

Complete your CHIRP Individual User Agreement online today to ensure access to important immunization information.