Pediatrics, OB/GYN, and Family Medicine Network Access Request

USER INFORMATION

*Employee ID:
*Employee Last Name:
*Employee First Name:
*Title:
*Supervisor:
*Requester Last Name:
*Requester First Name:
*Requester Email:	(this is where the new login information will be sent)
*Division:	[Select Division] -Other Administration Allergy/Immunology - 1641 Ambulatory Pediatrics Anesthesiology Cardiology - 1642 Cedars-Sinai Center For Healthy Child Chairman Child Amputee Program Child Development Child Health Policy - 1638 Children's Health Center Critical Care - 1644 Cystic Fibrosis Developmental Studies - 1643 Emergency Medicine - 1640 Endocrinology - 1645 Fiscal Affairs Gastroenterology - 1646 General Pediatrics - 1647 Genetics - 1648 Hematology/Oncology - 1649 Hospitalist Program Human Genetics Infectious Disease - 1650 Information Systems Legal Fees Medical Education Molecular Genetics - 1654 Neonatology - 1651 Nephrology - 1652 Neurology - 1653 Obstetrics/Gynecology Olive View Outside Pediatrics Pain Management - 1639 Patient Billing Office Personnel Public Health Pulmonary Medicine - 1640 Quality Assurance Radiology Respiratory Medicine Santa Monica Group Student Health
*Phone:
*BldgRoom:
Beeper:
Fax:

WORKSTATION INFORMATION

Computer:
Processor:

SPECIFIC PROGRAM ACCESS REQUESTS

Main Frame Access:
Mednet Email Account:
Computer login:
Description:

Bargaining Unit:

(if requesting Mainframe access)

*Mother's Maiden Name:

EMAIL DISTRIBUTION LIST(S)

Email Distribution List(s) that you wish to become a member of:

(Hold Ctrl key to select multiple listings.) Fam Med Community, Research and Fellowship Program Fam Med Everyone Fam Med Faculty Fam Med Research Fellows Fam Med Research Staff Fam Med Residency Support Staff Fam Med Residents Fam Med Residents and Fellows Fam Med SM-LKC Clinician Group Fam Med Staff Fam Med WW-FHC Clinician Group FMW Admin FMW Custodian Med Records FMW Faculty FMW Front Office FMW Med Rec FMW Nursing FMW Office FMW Staff OBGYN Academic Office OBGYN Everyone OBGYN Faculty OBGYN Fellows OBGYN Midwives OBGYN Practice Plan OBGYN Resident I OBGYN Resident II OBGYN Resident III OBGYN Resident IV OBGYN Residents PEDIATRIC AA's PEDIATRIC Allergy/Immunology PEDIATRIC Appointment Center PEDIATRIC Billing Supervisors PEDIATRIC Cardiology PEDIATRIC CHC Staff PEDIATRIC Child Development PEDIATRIC Community Based Medicine PEDIATRIC Critical Care PEDIATRIC Denial Task Force PEDIATRIC Division Chiefs PEDIATRIC DPGP Board Members PEDIATRIC DPGP Plan Members PEDIATRIC Endocrinology PEDIATRIC Everyone PEDIATRIC Executive PEDIATRIC Faculty PEDIATRIC Fellows PEDIATRIC Finance & Research PEDIATRIC Gastroenterology PEDIATRIC General PEDIATRIC Genetics PEDIATRIC Gonda PEDIATRIC Hematology/Oncology PEDIATRIC Housestaff PEDIATRIC Housestaff / ER PEDIATRIC Housestaff Chief Residents PEDIATRIC Housestaff Intern PEDIATRIC Housestaff PL2 PEDIATRIC Housestaff PL-3 PEDIATRIC Infectious Disease PEDIATRIC Information Systems PEDIATRIC Mail Administrator PEDIATRIC Managers PEDIATRIC MCIC PEDIATRIC Medical Education PEDIATRIC Neonatology PEDIATRIC Nephrology PEDIATRIC Neurology PEDIATRIC PAC Notifications PEDIATRIC Pain Program PEDIATRIC PCN PEDIATRIC Personnel PEDIATRIC PPBO PEDIATRIC Quality Improvement PEDIATRIC Residency PEDIATRIC Staff PEDIATRIC VPN Users

EMPLOYMENT HISTORY/STATUS (check all that apply)

Worked at UCLA Medical Center within the past 6 months:
Worked with the Department of Pediatrics in the past:
Worked with the Department of OB/GYN in the past:
Worked with the Department of Family Medicine in the past:
Temp or full-time employee:	Full-time Temp

This form is used to request access to the Department of Pediatrics, OB/GYN, and Family Medicine Local Area Network (LAN). This access entitles the undersigned to the conditional use of the Department's computing resources. These resources shall be used only for University business and said use shall be consistent with all University policies and practices. Network access shall be assigned on an individual basis and secured through the use of individual passwords. It is a policy violation to divulge individual passwords to others or to use a fraudulently obtained password to gain network access. Policy violations will be subject to loss of Network privileges. Changes in job responsibility may affect an individual's level of network access and must be reported to the Information Systems Manager immediately. I recognize that: 1. The Department of Pediatrics, OB/GYN, and Family Medicine licenses the use of its computer software from a variety of outside software developers. The Department does not own this software or its related documentation. Therefore, reproduction of either is illegal without the written authorization of software developer. 2. Departmental employees shall use this software and documentation only in accordance with existing licensing agreements. 3. Departmental employees learning of any misuse of software or documentation shall immediately notify the Information Systems Manager. By logging into the Pediatrics, OB/GYN, and Family Medicine Network, you agree and understand all of the above policies of the Department of Pediatrics, OB/GYN, and Family Medicine and will abide by them.