INFORMATION TECHNOLOGY ACCESS FORM

** Please Return Original to the IT Help Desk **

All information is this section is required for access assignment. Please print legibly.

Name: Thomas G. Triplett Employee ID#: Phone/Ext.

(First, Middle Initial, Last Name)

Job Title: Medical Student (OMS III) Campus: Newburgh Cornwall Other:

Dept/Nursing Unit: Manager’s Name

Effective Date: Person to notify when completed:

New Employee Employee Termination Menu Change Department Transfer

From Department: _____________
Returning Employee To Department: _____________

Traveler / Agency
Start Date: ____/____/_____
End Date: ____/____/_____

Check systems user will need access to:

Meditech Other Peoplesoft

Meditech E-Mail Midas HRPROD
Newburgh Campus GE Fetal Monitoring System FSPROD
Cornwall Campus Pyxis
ITS/RAD PACS (all Physicians to have access)
Internet Gateway (MDs) _____________________________________________________________

Menu Change to: ____________________________________________________________________________

This Meditech user needs the same access as (user name required):________________________

Teletracking Environmental Services requires BedTracking only

Nursing and Registration requires BedTracking and Pre-Admit Tracking
BedTracking

This Teletracking user needs the same access as (user name required):_______________________

Pre-Admit Tracking (Please select a Department and Group)

Department: Group:

4N HAMS 1W HAMS L.4N L.NICU

Bed Control IT Dept Cardiac Cath ICU L.5N Nsg.Leadership

Case Mgmt L.ED Case Mgmt IFACE L.7N PACU

Cath Lab Nrs Leadership Dept Pager L.1N L.BC Sup

Dept Pager Nursing Emergency L.2N L.ICU

ED PACU Exec.Team L.3N L.MB

Exec.Team
TransportTracking
 INFORMATION TECHNOLOGY ACCESS FORM
** Please Return Original to the IT Help Desk **

Network Access – List all that apply (e.g. Department Shared Drive, U Drive, etc.):

Outlook E-mail

1. Does this user need to access someone’s Outlook calendar? If so, please provide the existing user’s name and
select permission type:

User’s Name: Read Only Add/Remove Appointments

Does an existing user need access to the new user’s Outlook calendar? If so, please provide existing user’s
name and select permission type:

User’s Name: Read Only Add/Remove Appointments

2. Does the new user need to belong to any special Outlook Distribution Groups or need access to any Outlook
Public Calendars? If so, specify below:

Distribution Groups:

Public Calendar Access: Read Only Add/Remove Appointments

Internet Access: Please provide a description to justify this need: (required)

Voice Mail at Extension:

Physician Email Forwarding:

Personal Email Address:

Your SLCH email address (jdoe@slchospital.org) will forward automatically to the address you specify above.

CONFIDENTIALITY DISCLOSURE
All individuals employed by or associated with St. Luke’s Cornwall Hospital, have the responsibility to respect the
confidentiality of patient information at all times. Such information is provided only to those individuals involved in the
patient’s care or to those who have a legal right to the information.

User’s Signature Date

Department Manager (Please Print Your Name Here)

Department Manager’s Signature Date

FOR IT USE ONLY

IT Mgmt Approval: Date:

8431-02 Rev. 07/29/10