Custom Report Request Form

This document represents the final criteria for constructing a report. All requirements for the report must be accurately and concisely described below in order for the Allscripts Team to begin constructing the report. Any missing information will result in an incomplete design and may cause delays in development.

Custom report requests will be prioritized based upon the impact of the report on a group’s core operations and / or business needs, the complexity of the report and the availability of resources to develop the report.

Report Requestor

First NameLast Name

Date of Request

MonthDayYear

Phone Number

Area CodePhone Number

E-mail

Desired Report Title

Who is this report for?

Business Case for this report: (Why report is needed)

Report Description in Detail:

How will the report be grouped:

At what levels should the report be totaled or summarized:

How should the data be stored:

Expected Frequency:

Needs to be Completed by

Comments (if any):

Internal Use

Status:

Status Details:

Completed By:

First NameLast Name

Date:

MonthDayYear