Bronson System Student Account Request Form

Please complete the following steps:

  1. Please type all information when completing form.
  2. Each Student must fill out the BHG Confidentiality and Network Agreement Form, prior to submitting account request.
  3. Email the completed form to your Bronson liaison. (Forms sent directly to Bronson IT will not be processed.)
  4. Once received by Information Technology, please allow a 2-3 week turnaround time to complete accounts.

School: / Click here / Course Name: / Click here /
Term / Semester: / Click here / Start Date: / Click here / End Date: / Click here /
Practice where students will be based (Sponsoring Practice): Click here to enter text.
Bronson Liaison: Terie Caldwell / Phone 269-341-6522
Email: / Alternate: N/A
Clinical Faculty: / Click here / Phone Click here
Email: Click here / Alternate: Click here
School Administration Contact:Click here / Phone: Click here
Email: Click here / Alternate: Click here

Please submit the following information.

Student Full Legal Name (**If returning, please make note of any known name changes**)

First / M.I. / Last / Electronic Network Agreement form submitted / Previous Student at Bronson with access to Epic / Documenting in Epic (Y/N) / Practice
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N. / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /
Click here / Click here / Click here / Y/N / Y/N / Y / Click here /

Intranet access from Bronson electronic references & resources will be included with student accounts. Examples of expected used include: Bronson Policy & Procedure Manuals, Lippincott Nursing Reference, Health Sciences Library search engines for clinical research and patient teaching information. Student accounts will be frequently and regularly audited for logins and sites accessed. Inappropriate use will be investigated and reported to the student’s school.

Revision Date: July 11, 2014