Report Request Form (NPR:DR)
- 1. Information Services Hospital Name/Image ! ! ! ! ! ! Requestor Information Name: !Date Requested: Department: !Date Needed: Telephone/Ext: !Email: ! Run Frequency One Time Daily Weekly Monthly Quarterly Yearly Describe the purpose of this report: ! List all the fields that the report should include (example: Name, Address, Account Number, etc): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Define the selection criteria for the report (example: All patient visits between 1/1/12 – 1/1/14 for ER): ! If you would like the report sorted, list preferred sorting and indicate ascending or descending order: 1. 2. 3. 4. Ascending: Descending: ! | P a g e1
- 2. Information Services Hospital Name/Image ! ! Output File Format: Labels: MS Excel: Delimited Text: Indicate Delimiter:______ Printed Report: Other: __________________________ *****For Information Services Use Only***** Assigned To: Expected Comp Date: Report Name: Date Received: Tested By: Tested Date: Date moved to Prod: ! | P a g e2