School of Dentistry ID Card Request Form
School of Dentistry ID Card Request Form
Name
Name
*
First
Last
Middle Initial
*
Credentials
*
Credentials
DDS
DMD
PhD
RDH
Other
Other
Who will you be replacing?
Who will you be replacing?
*
First
Last
Department Name
*
Position Name
*
Start Date
Start Date
*
/
MM
/
DD
YYYY
Percent Effort
*
Percent Effort
Full Time
Part Time
Below 50%
Classification
*
Classification
Faculty
Staff
Volunteer
Externship
Parking
*
Parking
Yes
No
Do you need additional access to any of the following special areas? (Admin/Clinical building access granted automatically)
Do you need additional access to any of the following special areas? (Admin/Clinical building access granted automatically)
Admin Building - Sterilization
Admin Building - Gross Lab
Science Building
Will you be working in a clinical setting?
*
Will you be working in a clinical setting?
Yes
No
CPR Certification
*
CPR Certification
I am currently CPR Certified (Please bring a copy with you when you retrieve your ID Badge)
I am not currently CPR Certified (Please sign up for CPR when you retrieve your ID Badge)
A background check has been performed
*
A background check has been performed
Yes
No
Supervisor may be contacted to clarify access levels.
Supervisor Name
Supervisor Name
*
First
Last
Supervisor Email
*
Supervisor Phone
Supervisor Phone
*
-
###
-
###
####
Employee replacing anyone?
*
Employee replacing anyone?
Yes
No
If yes, who:
*
Requires AxiUm Access
*
Requires AxiUm Access
Yes
No
If yes, Same AxiUm Access as:
*
Requires AxiUm Trainer
*
Requires AxiUm Trainer
Yes
No
Approve: X-Rays
*
Approve: X-Rays
Yes
No
Submitted by:
Submitted by:
*
First
Last