Associated Personnel Identification Badge Form

Associated Personnel Identification Badge Request Form

Document: frmhr_emp_ap_id_badge_req

The Hospital requires all Associated Personnel to wear an identification (ID) badge while on Hospital property. To receive an ID badge all Associated Personnel must present the completed form(s) described below and a government-issued photo ID to Human Resources 1 Autumn Street, 1st floor before beginning their assignment. Associated Personnel who are on Hospital property for:

· less than two weeks must submit this form

· more than two weeks and who have direct patient contact must submit BOTH this form and the Associated Personnel Health Screening form.

The requesting department is responsible for printing these forms and giving them to the Associated Personnel in advance of their assignment to allow time for completion. If you are an MD/PhD who will have direct patient contact, you must obtain an approval signature from Medical Staff Services as indicated below.

Demographics

To be completed by the Associated Personnel.
Last Name / First Name / MI
Home Street Address / Apt#
City / State / Zip
Education Level / Credentials
Date of Birth / Country of Birth
SS# / Telephone no.
Emergency contact / Telephone no.
Home Institution (name of employer/school, etc) / Email address (personal or work)

Personnel Type

To be completed by the Department’s authorized person. Select the classification from the list below.
Type of Associated Personnel / Timeframe* / Type of Associated Personnel / Timeframe*
Affiliated Non-clinical staff / 1 year / Nursing Student / 1 year
Agency Temp / 6 months / Observer / 3 months
Auditor/Outside Reviewer / 6 months / Professional Service Provider / 1 year
CHB Support Service Provider / 1 year / Research Fellow / 1 year
CHB Tenant / 1 year / Social Work Student Intern / 9 months
Construction Contractor / 1 year / Student Trainee/Intern / 3 months
Howard Hughes Medical Institute Affiliate / 1 year / Teacher / 6 months
Independent Contractor/Sole Proprietor / 1 year / Traveler / 6 months
Medical Student / 6 months / Visiting Scientist / 1 year
Non-Physician Clinician (Licensed) / 1 year / Visitor (Non-med staff) / 2 weeks
Medical Staff (MD/PhD only)
Senior Staff / House Staff / Affiliating House Staff
Description of assignment
Start date of assignment / End date of assignment
Home Department Code (HDC)
PeopleSoft Location Code (see pg 2)
Computer Account Access Only (a Children’s Hospital ID Badge will not be issued)
Check this box if the Associated Personnel works off-site and the ID number will be issued for computer access only.
^ / Direct Patient contact means the individual is in the room where patient care is given, e.g., exam room, operating room, treatment room, patient bedside, outpatient clinic.
* / Timeframe cannot be changed. To extend ID badge activation, the Associated Personnel must resubmit this form prior to their ID Badge expiration date.

Authorization

The Department Director or Administrator who initiates the relationship with the Associated Personnel is responsible for authorizing an identification badge request.
This department is requesting an identification badge for the above named Associated Personnel. This Associated Personnel has a business reason connected to this department for coming onto Hospital property. This department will assume responsibility for this person’s access to Hospital property. The Associated Personnel has been instructed to read and sign the Certification Agreement listed below.
Department Director or Dept. Administrator (print name) / Ext/Beeper
Department Director or Dept. Administrator Signature / Date
For Credentialed Medical Staff Only. Medical Staff Services authorizes all credentialed MD/PhD Associated Personnel who will have direct patient contact as indicated below.
Medical Staff Services Administrator (print name) / Ext/Beeper
Medical Staff Services Administrator Signature / Date

Certification Agreement

I understand that disclosure of confidential patient or Hospital information is prohibited by Hospital policy. I agree to abide by all Hospital policies relating to confidentiality. I agree to abide by all Hospital rules, by-laws, regulations, procedures, and policies. I agree to surrender my identification badge and other Hospital property at the end of the term for which the badge or property was issued, or earlier upon request. I understand that the Hospital is free to request return of the badge or property at any time, with or without cause, and with or without notice. I understand that obtaining an identification badge or other Hospital property does not create in me or entitle me to any of the benefits of employment at the Hospital nor create any obligations on the part of the Hospital to me. I also understand that access to Hospital information systems is authorized separately by the Information Systems Department and obtaining a personnel number and identification badge does not entitle me to access to Hospital information systems.

Signature of Associated Personnel / Date

Location Codes (For Department Use Only)

AUTUMN / BOYL02 / ENDE02 / FARL01 / FEGA04 / HARV02 / LONG03 / MAIN7N / OFFSITE / RB0008
BADE01 / BOYL03 / ENDE03 / FARL02 / FEGA05 / HARV03 / LONG04 / MAIN7W / PAVI01 / RB0009
BADE02 / BOYL04 / ENDE04 / FARL03 / FEGA06 / HOMECR / LONG05 / MAIN8E / PAVI02 / RB0010
BADE03 / BROCKT / ENDE05 / FARL04 / FEGA07 / HUNN01 / LONG06 / MAIN8N / PAVI03 / RB0011
BADE04 / BROOK / ENDE06 / FARL05 / FEGA08 / HUNN02 / MAI10E / MAIN8W / PAVI04 / RB0012
BADE05 / BURL01 / ENDE07 / FARL06 / FEGA09 / HUNN03 / MAI10N / MAIN9E / PAVI05 / SMIT01
BADE06 / BURL04 / ENDE08 / FARL07 / FEGA10 / HUNN04 / MAIN01 / MAIN9N / PAVI06 / SMIT02
BADE07 / CARN01 / ENDE09 / FARL08 / FEGA11 / HUNNGF / MAIN02 / MAIN9W / PAVILO / SSHORH
ADE08 / CARN02 / ENDE10 / FARL09 / FEGABB / JUDG01 / MAIN03 / MAINBB / PEABOD / TREM01
BADE09 / CARN03 / ENDE11 / FARLB1 / FEGAPL / JUDG02 / MAIN04 / MAINSB / RB0002 / WINCHE
BEVERL / CONV / ENDE12 / FARSB1 / FEGASB / JUDG03 / MAIN05 / MEHC01 / RB0004 / WOLB01
BINN01 / CONV2 / ENDE13 / FEGA01 / GALL01 / JUDG04 / MAIN6E / MEHC02 / RB0005 / WOLB02
BINN02 / EMMANU / ENDEB1 / FEGA02 / GALL02 / LEXING / MAIN6W / METROW / RB0006 / WOLB03
BOYL01 / ENDE01 / ENDSB1 / FEGA03 / GARAGE / LONG02 / MAIN7E / NORWOD / RB0007 / OLBBW

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