Qies Access Request PDF Details

The Qies Access Request Form is a new form that was recently released by the Queen's Information and Educational Services (QIES) department. The form is designed to streamline the process of requesting access to certain Queen's University resources and services. The form can be accessed on the QIES website, and it is important to note that completion of the form is required in order to gain access to many of the resources and services offered by QIES. Some of the benefits of using the form include streamlined processing times and improved communication between requesters and QIES staff. I encourage everyone who needs access to Queen's University resources or services to take a few minutes to fill out the Qies Access Request Form.

You can find info about the type of form you would like to prepare in the table. It can show you how long it will take to finish qies access request, what parts you will have to fill in, etc.

Form NameQies Access Request
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesdo qies, qies access request, qies reports, cms qies corporate access request form

Form Preview Example

QIES National Data Access Request.

Please complete this form electronically, print, and sign hard copy to submit

Type of Request

New User ID

Change Access

Delete User ID

Existing QIES User ID (CASPER, QW, ASPEN Web):

Access Requested For

Type of User:


State Survey Agency


DUA Number:




DUA Expiration Date:






Requester Name:



















Last, First, Middle Initial



Carrier Number (MAC Only):



User Location: City: Work Phone Number: Work E-mail Address: Access to States:

State: Extension:

Request Date:

CASPER Reports Access

MDS NH Reports

MDS SB Reports

OASIS Reports (inc. OBQI/OBQM Mgmt)

Survey & Certification Reports


CLIA MSA Report 91

IRF-PAI Management

IRF-PAI Administration


MDS NH Assessment

QIES Workbench Access


Survey and Certification (Includes Provider/Enforcement (AEM) and CLIA data)


The QIES Workbench data groups below contain patient-level (privacy) data















ASPEN Web Access



Other Access

RHHI Extract

MDS NH Extract

MDS 3.0 NH Viewer

MDS Training Worksheet

IRF-PAI Viewer


MDS SB Extract

Swing Bed Viewer

OASIS Training Worksheet



OASIS Viewer




Other access not listed:









Business need for the













requested access:











Supervisor Authorization -

Supervisor Authorizer Name:









Last, First, Middle Initial





Supervisor Authorizer Phone:








Required for Approval

Supervisor Authorizer Signature: (sign in black or blue ink)


CMS Regional Office CMS Authorizer Name:

CMS Authorizer Phone:

CMS Authorization - Required for Approval

CMS Central Office

CMS Authorizer Signature: (sign in black or blue ink)

Last, First, Middle Initial







QIES National Data Access Request - Revised 03/31/2015


Privacy Act of 1974, P.L. 93-579

The information on side 1 of this form is collected and maintained under the authority of Title 5 U.S. Code, Section 552a(e)(10). This information is used for assigning, controlling, tracking and reporting authorized access to and use of CMS’s computerized information and resources. The Privacy Act prohibits disclosure of information from records protected by the stature, except in limited circumstances.

The information you furnish on this form will be maintained in the Individuals Authorized Access to the Centers for Medicare & Medicaid Services (CMS) Data Center System of Records and may be disclosed as a routine use disclosure under the routine uses established for this system as published at 59 FED. REG. 41329 (08-11-94) and as CMS may establish in the future by publication in the Federal Register.


CMS uses computer systems that contain sensitive information to carry out its mission. Sensitive information is any information which the loss, misuse, or unauthorized access to, or modification of could adversely affect the national interest, or the conduct of Federal programs, or the privacy to which individuals are entitled under the Privacy Act. To ensure the security and privacy of sensitive information in Federal systems, the Computer Security Act of 1987 requires agencies to identify sensitive computer systems, conduct computer security training, and develop computer security plans. CMS maintains a system of records for use in assigning, controlling, tracking and reporting authorized access to and use of CMS computerized information and resources. CMS records all access to its computer systems and conducts routine reviews for unauthorized access to and/or illegal activity.

Anyone with access to CMS Computer Systems containing sensitive information must abide by the following:

-Do not disclose or lend your IDENTIFICATION NUMBER AND/OR PASSWORD to someone else. They are for your use only and will serve as your “electronic signature”. This means that you may be held responsible for the consequences of unauthorized or illegal transactions.

-Do not browse or use CMS data files for unauthorized or illegal purposes.

-Do not use CMS data files for private gain or to misrepresent yourself or CMS.

-Do not make any disclosure of CMS data that is not specifically authorized.

-Do not duplicate CMS data files, create sub files of such records, remove or transmit data unless you have been specifically authorized to do so.

-Do not change, delete, or otherwise alter CMS data files unless you have been specifically authorized to do so.

-Do not make copies of data files, with identifiable data. Or data that would allow individual identities to be deduced unless you have been specifically authorized to do so.

-Do not intentionally cause corruption or disruption of CMS data files.

A violation of these security requirements could result in termination of systems access privileges and/or disciplinary/ adverse action up to and including removal from Federal Service, depending upon the seriousness of the offense. In addition, Federal, State and/or local laws may provide criminal penalties for any person illegally accessing or using a Government-owned or operated computer system illegally.

If you become aware of any violation of these security requirements or suspect that someone else may have used your identification number or password, immediately report that information to your security officer.

Signature of User: (sign in black or blue ink)


Printed User's Name:

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