CalREDIE Local Health Department Staff Account Authorization Form

A Local Health Department (LHD) Staff user is any individual authorized by a LHD Liaison to access the CalREDIE system. system. Please complete the Account Authorization AND the HIV Confidentiality Agreement sections and click Submit. Your account request will then be routed to your LHD liaison for approval.

* = Required Field

Step 1 - LHD Registration Information
Step 2 - Confirm Submission

Action and LHD Selection

Account Action

Local Health Jurisdiction

Delete all accounts

Accounts to be deleted

LHD Staff Registration Information

First Name

Last Name

Work Street Address

City

State

Zip Code

Direct Work Phone Number

Extension

Work E-Mail

Email Address Type

LHD Staff Signature

LHD Staff Signature Date