Student Nurse Form
Total Page：16
File Type：pdf, Size：1020Kb
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