MILITARY HEALTH SYSTEM/INFORMATION MANAGEMENT

INSTRUCTIONS FOR

COMPLETING THE MHS CHANGE REQUEST FORM

Purpose: To provide the form and instructions for submitting new requirements or changes to Military Health System (MHS) automated information systems (AISs). Who Should Use This Form: Any member of the MHS who would like to recommend: A change to an existing MHS AIS A new capability that a MHS AIS should support How to Complete This Form: Refer to the form instructions on the following pages. Please complete the form as instructed. Where to Send This Form: Once completed, this form may be sent to TRICARE Management Activity, Information Management (IM) Division by email to: IMIT_Reqs@tma.osd.mil. IM Response: A member of the IM Division Will: Send you an email confirming receipt of your submission Provide you with a submission number Questions: Contact IM at IMIT_Reqs@tma.osd.mil

MHS Change Request Submissions Instructions

The following instructions apply to completing the MHS Change Request Form.

Date of Submission: Enter the date on which you are submitting your recommendation. (yyyy-mm-dd)

Request Type: Please select your request type from the drop down menu.

Electronic System(s) involved: Please enter the electronic system, including configuration and version number, involved in your request.

Short Description of Problem: Briefly describe the problem that you want yourself and other users to overcome. If you have one, include a brief description of how you would propose solving the problem. This will help ensure that a complete understanding of your concern.

MHS Help Desk: Please indicate if you have contacted the MHS Help Desk or other support entity for assistance. If so, enter the tracking number you were given.

MHS Help Desk Directions/Comments (if any): If you contacted a support entity, please document the instructions you were given. If you did not contact a support entity, leave this section blank.

What outcome do you want to achieve? Describe the benefit that you would like to see realized from this change. What outcome will change? What workflow will change? Briefly describe how this change will be used or impact typical processes. State if you think this will require a change of policy. If so, indicate which policy. If this is a mandated change, a copy of the exact citation/regulation is required.

Existing Work Around: Is there an existing work around to the current limitations? If yes, please document it here and annotate why this is not an acceptable solution.

Urgency: (High, Medium, Low): Use the table below to determine the urgency of your request.

Urgency	Definition
High (Appropriate justification must be provided)	Jeopardizes patient safety, information security, or accomplishment of a mission essential capability AND NO WORK-AROUND EXISTS.
Adversely affects technical, cost, or schedule risks to the project or to the life-cycle support of the system AND NO WORK-AROUND EXISTS.
Medium	Adversely affects the accomplishment of an operational mission essential capability; however a work-around solution is known.
Adversely affects technical, cost, or schedule risks to the project or to the life-cycle support of the system; however a work around solution is known.
Low	Results in user operational inconvenience or annoyance but does not affect a required operational or mission essential capability.
Other changes or features considered “nice to have”

Urgency Justification: Specific details on how the request meets the criteria as defined in the table above MUST be provided to have this request considered as a High Urgency

Service Approval: Please list the contact information of the approver in your Service Branch.

Your Service Branch: Please select your Service Branch.

Your Contact Information: Please list your contact information and title.

Supervisors Contact Information: Please list the contact information of your supervisor.

How to do a Screen Capture and embed it in the form: Viewing the screen you wish to capture, using your keyboard simultaneously press the ALT Print Screen buttons (on some computers this may be Fn Print Screen). This will capture the current view on your screen. Place your cursor in the capture a screenshot box on the Change Request Form. Then on the top tool bar select Insert > Object. This will open a new window, in this window, select Microsoft Word® – make sure the Display as icon button is checked. Then press OK, a blank word document will open. In this blank document, paste the screenshot you captured previously by pressing CTRL v on your keyboard. After pasting the screenshot into the word document, close the window. You will now see a word icon on the form. When you save the form, the embedded screenshot will be saved with it. Double click on the icon to test that the embedding worked.

MHS Change Request Form

Section A: To be completed by the Submitter
1. Date of Submission:	2. Request Type:
3 (a) Which electronic system(s) does this submission involve: (i.e. (AHLTA, CHCS, CCE, etc)	3 (b) Configuration:	3 (c) Version:
4. Short Description of Problem:
5 (a) Did you contact the MHS Help Desk or other support entity for assistance? Yes No	5 (b) If yes, Tracking Number :
6. What were the directions or comments given to you by the Help Desk:
7. What outcome do you want to achieve? (Please be specific)
8 (a) Is there an existing work around to the current limitations? Yes No N/A	8 (b) If yes, briefly describe:
8 (c) If the workaround is not acceptable, explain why:
9. Urgency: (See table on instruction page)Select one High** Medium Low	10. Justification for High Urgency**:
11. Who in your Service has approved this request?
Name:	Phone:	Email:
12. Your Service Branch: Army Air Force Navy Other N/A
13. Submitter’s Contact Info:
Name:	Phone:	Email:
Submitter Role: (e.g., physician, administrator, pharmacist, etc)	Submitter’s Agency/Address:
Other:
14. Supervisor Contact Info:
Name:	Phone:	Email:
Screen shots or other pertinent documentation can be very helpful. Please embed a file as an object, if possible. Please embed all screenshots in a PowerPoint or MS-Word file and comments/text can be added to clearly describe your issues. See Instructions for how to capture a screenshot and embed objects into this document.
Thanks for completing this Section! Please send this form to IMIT_Reqs@tma.osd.mil