<p> PINNACLE HEALTH SYSTEM XXXX Add INFORMATION SERVICES DEPARTMENT Change SECURITY REQUEST FORM Delete NURSING FACULTY REQUEST</p><p>Requestor Information: (this section must be completed for all requests)</p><p>First Name: MI: Last Name: </p><p>PHS Title: Nursing Faculty Faculty ID # (last 4 digits): DOB: (mm/dd/yyyy)</p><p>Cost Center: Learning Institute</p><p>Program: HACC RN/LPN Messiah RN Penn State RN York RN Other </p><p>Dept. Mgr: Tiffany Boyd - Student Placements</p><p>Need by: Miscellaneous information:</p><p>Are you currently a Pinnacle employee with a log-in? Yes No If yes, what is your Employee Network Logon </p><p>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</p><p>MAK Badge ID # </p><p>SOARIAN – Clinicals Model: ccrn</p><p>Reminder: All Student Instructors need to be set up in Innovian Servers HH CG WS</p><p>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</p><p>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</p><p>Revised 10/29/14 </p>