CDPH State Staff Account Authorization Form

A California Department of Public Health (CDPH) State Staff user is any individual authorized by a CDPH Branch or Program Liaison to access the CalREDIE system.

Please complete the Account Authorization AND the HIV Confidentiality Agreement sections and click Submit. Your account request will then be routed to your Branch or Program liaison for approval.

* = Required Field

Step 1 - State Staff Registration Information
Step 2 - Confirm Submission

Action

Account Action

Branch

Delete all accounts

Accounts to be deleted

State 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

State Staff Signature

State Staff Signature Date