IAR Reports Recipient Form

For health service providers who are uploading assessments to the Integrated Assessment Record (IAR)

This electronic form is to be used for identifying a maximum of two recipients for each common assessment standardized reports g
by the IAR. Please fill out a form for each type of common assessment you have completely implemented (eg. OCAN or interRAI C
This form is also to be used to update changes to the name, title or email address of your report recipients or change of name or d
your organization.
Sections A (below) and G (other side of this page) are mandatory. The other sections of this form are relevant when your organiza
needs to:
1. Add a reports recipient(s) – complete Section B
2. Modify information about an existing recipient(s)— (name, title or email address) -- complete Section C
3. Modify information about your organization -- complete Section D Check the b
4. Remove a reports recipient or discontinue receiving reports – complete Section E if you wish t
5. Reset my password – complete Section F reports in F
well.
Please complete this form electronically — including signing the back of this page -- and send to IAR at
iar@ccim.on.ca.

For further information on how to complete this form, contact the Support Centre at iar@ccim.on.ca or 1.866.909.5600
What assessment will you be uploading?
Section A – Mandatory Information interRAI CHA Ontario Common Assessment of Need (OCAN)
Both
Organization Name: Org ID/MIS ID/Master ID (if known)
     
IAR End User Internet Protocol (IP) Address Action Requested: (Choose from actions B – F below) Date Action Requested: (dd/mm/yyyy)
         /    /     
Section B – Add Report Recipient

Add Report Recipient 1

First Name       Last Name      

Title/Position       Email      @     

Add Report Recipient 2
First Name       Last Name      
Title/Position       Email      @     
Section C – Change Report Recipient Information

Change Report Recipient 1

Current First Name       Current Last Name      
Current Title/Position       Current Email      @     
New First Name       New Last Name      
New Title/Position       New Email      @     
Account information to be changed on or before (dd/mm/yyyy): Reason for change: (if a replacement, fill out section E)
   /   /           

Change Report Recipient 2

Current First Name       Current Last Name      
Current Title/Position       Current Email      @     
New First Name       New Last Name      
New Title/Position       New Email      @     
Reason for change: (if a replacement, fill out section E)
Account information to be changed on or before (dd/mm/yyyy):
     
   /   /     

Integrated Assessment Record

Email: iar@ccim.on.ca; 1.866.909.5600
 Please sign authorization on the other side of this page.

Section E – Remove Report Recipient Information

Remove Report Recipient 1 Information
First Name       Last Name      
Email      @      Account to be removed on or before (dd/mm/yyyy):   /    /     
Special instructions
     
Remove Report Recipient 2 Information
First Name       Last Name      
Email      @      Account to be removed on or before (dd/mm/yyyy):   /    /     
Special instructions
     

Section D – Change Organization Information

Current Organization Name: Current Org ID/MIS ID/Master ID (if known)

           
New Organization Name: New Org ID/MIS ID/Master ID (if applicable)
           
Account information to be changed on or before (dd/mm/yyyy): Reason for change:
   /   /           

Integrated Assessment Record

Email: iar@ccim.on.ca; 1.866.909.5600
 Section F – Reset Password
Reset Password for Recipient 1
First Name       Last Name      
Email      @     
Reset Password for Recipient 2
First Name       Last Name      
Email      @     

Section G - Authorization The Executive Lead must authorize the add, change, or removal of a user’s access to IAR Reports by signing below
The designated reports recipients have received privacy training and are aware of this organization's obligations as a Health Information Custodian and will not u
the information in these reports to attempt to re-identify individuals.
First Name Last Name
           
Email Phone No
     @                  
Signature

For Internal Use Only

CCIM Support Centre Ticket Number       Date when DSA takes effect or was withdrawn :    /    /     
Executive Lead Verified Request Completion Date in IAR    /    /      Request Completed by:      
HSP is entitled to receive reports Notes

Integrated Assessment Record

Email: iar@ccim.on.ca; 1.866.909.5600