OHSU - Access ID Card form httpozone.ohsu.edupubsafetyid by nsr11162


									                                                                                                                                                      Print Form
                                                                               OHSU ID Badge
                                        Please bring the following five (5) items listed below to obtain your ID badge:

            1.   HIPAA TRAINING CERTIFICATE (required for all work force members)
            2.   RAU TRAINING CERTIFICATE (required for all work force members)
            3.   BACKGROUND CHECK (bring clearance email from Public Safety)
            4.   VALID GOVERNMENT-ISSUED PHOTO I.D. - Any of these will be accepted: drivers license, state I.D. or passport.

            Today's Date:                                                          Employee ID#:

            First Name:                                                            Last Name:

            OHSU Affiliation

                  Employee (choose type):                Regular            Temp            Resource             Non-OHSU Student

                 Student*             Volunteer*              Visiting Scientist*             Vendor              Board              Foundation               Visitors

                 OHSU Building Tenant*                       Contractor*         Company:                                           Phone:

            Expiration Date:

            * Non-Employees (Students, Volunteers, and Contractors) must indicate the expected termination date for access rights. Access rights will automatically
            terminate after this date. This information is mandatory for all non-employees. Card holders are responsible for notifying the Customer Service Center of
            any changes to this date. Extension will require a completed request form for renewal.

            Job Title: Nursing Student                                                      Credentials:

            Department:                                                                                  Dept. Phone Ext: x4-8185

           Dept. Manager Signature:                                                           Please Type/Print Name:

           Recipient's Signature:

            Oracle Alias#: self-pay                                                           FAID#:
           ($15.00 fee for ID badges: 8 digits required)
            We are unable to process your request without the correct billing information.
            Select Card Type:

                      New Card                                 Renewed/Updated                                    *Stolen                             *Lost
                      * Click here if you had scrub access on your previous ID Badge

                            Replacement of lost ID card is $15.00. Add $246.00 to total if TriMet or C-Tran PassPort was attached.

       Please grant me access to the following location(s): Some areas require additional signatures.
       Please refer to Access Card Requirement list at http://ozone.ohsu.edu/parking/pages/access_card_authorize.htm

       OHS, DCH, VA, ED, KPV

           I accept responsibility for the above listed ID/access card. I agree to notify Public Safety immediately should this card become lost
           or stolen. I agree to be the sole user of this access card and return it upon termination of my affiliation with OHSU.

       Recipient's Signature:

                                 Print form and bring to the Parking Office with all required documents to receive your ID badge.

         ******************************************************For Office Use Only******************************************************

         Card # Issued:                                       Date Issued:                                          Issued By:

OHSU - Access & ID Card form                                                                                          http://ozone.ohsu.edu/pubsafety/id/id_badge.pdf

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