Student Nurse Form - DocsLib

Student Nurse Form

PINNACLE HEALTH SYSTEM XXXX Add INFORMATION SERVICES DEPARTMENT Change SECURITY REQUEST FORM Delete NURSING FACULTY REQUEST

Requestor Information: (this section must be completed for all requests)

First Name: MI: Last Name:

PHS Title: Nursing Faculty Faculty ID # (last 4 digits): DOB: (mm/dd/yyyy)

Cost Center: Learning Institute

Program: HACC RN/LPN Messiah RN Penn State RN York RN Other

Dept. Mgr: Tiffany Boyd - Student Placements

Need by: Miscellaneous information:

Are you currently a Pinnacle employee with a log-in? Yes No If yes, what is your Employee Network Logon

Network accounts are granted to every Student Nurse Instructor SSO Group SSO – Multiple Signon Group Note: this needs to be set up if instructor is also an employee

MAK Badge ID #

SOARIAN – Clinicals Model: ccrn

Reminder: All Student Instructors need to be set up in Innovian Servers HH CG WS

INSTRUCTOR INSTRUCTIONS: This form – type directly on form - email to: [email protected] Confidentiality Form - scan and email to: [email protected] or fax to: Tiffany Boyd at 717-221-6266 Questions – Call Tiffany Boyd at 717-221-6214

Instructors are from: HACC, Messiah, Penn State, or York ======Security INSTRUCTIONS: Revised 10/29/14 1. Open Event under Tiffany Boyd’s name 2. Set up Security appropriately 5. Email Security Notification forms back to Tiffany Boyd

Revised 10/29/14

2