HEALTH ECONOMICS AND FINANCING DIRECTORATE
(HEFD)
RESOURCE TRACKING UNIT
EMIS DATABASE USER ACCESS REQUEST FORM
Name of Requesting Organization: Click or tap here to enter text.
Department/Program Area: Click or tap here to enter text.
Username 1(to be filledUser
Nominating/Candidate 1: only):
by HEFD
Username 2 (to be filled by HEFD only):
(Details of user who will be given the permission to access and use online EMIS)
First Name: Click or tap here to enter text.
Last Name: Click or tap here to enter text.
Position: Click or tap here to enter text.
E-Mail: Click or tap here to enter text.
Cell Phone: Click or tap here to enter text.
First Name: Click or tap here to enter text.
Last Name: Click or tap here to enter text.
Position: Click or tap here to enter text.
E-Mail: Click or tap here to enter text.
Cell Phone: Click or tap here to enter text.
Nominating/Candidate User 2:
(Details of user who will be given the permission to access and use online EMIS)
Requesting Officer:
(Details Project /Agency Head or Chief of Party or Executive Director)
HEALTH ECONOMICS AND FINANCING DIRECTORATE
(HEFD)
RESOURCE TRACKING UNIT
EMIS DATABASE USER ACCESS REQUEST FORM
First Name: Click or tap here to enter text.
Last Name: Click or tap here to enter text.
Position: Click or tap here to enter text.
Official Email: Click or tap here to enter text.
Cell Phone: Click or tap here to enter text.
Organization Stamp:
To be filled by Heath Economics and Financing Directorate (HEFD)
Organization Name:
Full Name:
Username 1: Password:
Full Name:
Username 2: Password:
Term of Use
For Nominating Users:
HEALTH ECONOMICS AND FINANCING DIRECTORATE
(HEFD)
RESOURCE TRACKING UNIT
EMIS DATABASE USER ACCESS REQUEST FORM
1. We understand that we are responsible for maintaining the security and integrity of all
expenses related to my organization in the EMIS database and using the data
appropriately.
2. We understand that we will be responsible for writing and reading my organization
health expenditure data into EMIS, allow EMIS database to record my username in
the EMIS database for each record I write into database
3. We acknowledge our responsibility for the proper use of EMIS data, timely reporting,
and adherence to all requirements set forth by the Ministry of Public Health (MoPH)
and EMIS guidelines
4. We understand that the usernames are our own individual/organizational code for
gaining access to EMIS.
5. We agree to protect the usernames and password confidential, and not disclose it to
any other person.
Signature 1: Signature 2:
Date: / /
For Requesting Officer:
1. I understand that the usernames are our own individual/organizational code for
gaining access to EMIS and will be responsible for all EMISS data reported under this
username into online EMIS database.
2. I agree to immediately report EMIS, when the users with the above detail role
changes or leave this organization to revoke their access to the EMIS system.
3. In the event of any misuse of the system or the data derive from the system, I agree to
inform MOPH/HEFD as soon as possible.
4. I understand that users are given the right to access EMIS system (data entry) and I do
monitor these users to ensure that appropriate data is given to EMIS/MOPH.
Organization Stamp: Signature: Date: / /
