Page 171 - CHST Research Administration eBook 2 of 2 (Q4 2021)
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AdHoc Access Request
2019
Instructions:
This form must be filled out by a Children’s employee. Once complete, the employee will forward it to their supervisor1 for approval. Once approved, the approver will send the form along with their electronic signature to AccessManagement@Childrens.com to be processed. SLA for completion is 3-5 business days once a completed and approved form is received.
Contact Information
Children’s Employee
Approving Supervisor
Name Phone# Email Department
Enter Coordinator information here
Name Phone# Email Department
Deborah Town
214-456-2253
deborah.town@chil
Professional Servic
New User Information
Name Phone# Email Employer
Title
Reporting department
Requested Start Date
Expiration Date (Not to exceed one year)
Will user be on site for more than Yes 5 days?
En
ter monitor information here.
Enter start date of visit.
Please provide three of
No
Check "No"
the below identifiers.
Monitor to provide 3 identifers below
d e
Four-digit PIN:
Last four of Social security:
Date of birth:
Mother’s maiden name:
Make of first car:
Name of best friend:
Name of high school mascot:
1 Approver must be of Manager level or above for IS or Team Lead or above for clinical.
