TCP Provider Barring Notice Request Tracker (Updated)

TCP Provider Barring Notice Request Tracker (Updated)

The Barring Notice Request Tracker will be used to monitor all barring notice requests submitted to Kimberly Baxter (DHS) at Kimberly.Baxter2@dc.gov as well as approval status. This tracker will be used to develop a system where all barring notice requests will be submitted here after it is submitted to DHS.

This report must be completed in its entirety and an attachment of the submitted barring notice request is required with every submission.

Provider Name*

Select

Name of Program in which Barring is requested*

Select

Name of Person Submitting the Notice*

Title of Person Submitting the notice*

Email Address of Person submitting Notice*

Name of Barred Individual*

Reason for Barring Request*

Please provide a brief summary of the incident that occurred which resulted in a request to bar the individual

Was a Corresponding UIR Submitted to Both DHS and TCP to support the barring request?*

Please note that all UIRs must be submitted to DHS via the QuickBase system. All UIRs must be submitted to TCP via the TCP UIR Smartsheet Tracker. The link for the TCP UIR Smartsheet tracker is below:

https://app.smartsheet.com/b/form/5324a09a6b384875a64c125d6c848c17

Select

Date of UIR Submission*

Corresponding UIR AC Number*

The UIR AC number is the UIR identification number that can be found at the top of the Submitted UIR Report Form

Was the Barring Notice Request sent to Kimberly Baxter (DHS) for approval*

All barring notice requests should be sent to Kimberly Baxter at Kimberly.Baxter2@dc.gov for approval.

Select

Date of Submission to Kimberly Baxter at DHS*

Submitted Barring Notice Request Form*

Please upload the completed Barring Notice Request that was forwarded to Kimberly Baxter (DHS) for approval.

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse