Page 189 - CHST Research Administration eBook 2 of 2 (Q4 2021)

AdHoc Access Request
2019
Please select the type of relationship for this user
Consultant Vendor Volunteer
Is the person for whom access is being requested in the process of or subject to being credentialed/screened by any of the following Children’s Departments:
• Human Resources (fulltime/part time children’s employees and contractors)
• Graduate Medical Education (fellows, residents and medical students)
• Medical Staff Services (physicians, advanced practice nurses, allied health professionals)
• Clinical Education (nursing students)
If so, then stop, do not complete this form. Please contact the Children’s Department that processes that category of staff.
No Yes
Approver attests that this user complies with all applicable HR on boarding processes
No Yes
Please check all that apply for whom access has been requested
Previously employed by Children's Previouslyemployed by UTSW orParkland Currently employed by UTSW or Parkland
Approver attests, if this user is to gain access to Sensitive or Restricted data, that they are bound by a confidentiality statement, either documented within the contract for services or Children’s Third Part Confidentiality Agreement.
No Yes
Business justification:
Research Monitor Visit for (add) - PI last name>short study title (if known)>STU number
Requested Access
iSite Epic
Network P: Drive
Stream Line Health M: Drive