Department of Community Health and Family Medicine

Submit this form with an original signed Appropriate Use of University Computers and Networks

Information Services Network/User ID/ Password Request Form * - Indicates required fields. User Info*: Please Check one New Employee Access ChangeName Change Add Access Full Name*:Last, First, Middle initial Requesting Supervisor's Name*: UF ID #*: Requesting Supervisor's Email*: Location (Building.)and Room #*: Work Number and Extension*: User Gatorlink ID*:(must be created before other accounts) Title*: Hire or Account Requested By Date*: Program/Clinic*: Required Access and /or applications:  Check all that apply UF Network Account (CHFM file and print) Security Access to Fiscal folder Security Access to Budget folder Security Access to Chair folder Security Access to Personell-Payroll folder Security Access to Security folder Security Access to Trials (restricted data including PHI) Security Access to Compliance PHI folder (restricted data including PHI) Security Access to Compliance Referral Logs (restricted data including PHI) Security Access to Student Records folder (restricted Student data) Security Access to CHFM Web folders (local and online for webmaster) Security Access to some other resource (specify resource in comments) Exchange Email and Calendaring new user account Exchange Proxy or Shared calendar Access (specify in comments) Budget Software read only Budget Software read/write Password Reset (specify account and reason in comments) Comments for Account Management:

Last Updated: November 20, 2007