Employee Security Form (workflow) V3 Header Image

Employee Security Form

Supervisor/Manager To Complete

Date Hired:*
If you click "Other (Not listed)" you must type the job title here.
Check One:*
Is this a 3rd shift CDT needing access to the Nursing Census folder?
Is this staff member an Intern or Contractor?*
If YES, you must contact Fairbanks IT to acquire additiional starting paperwork.
Security Fob Needed:*

Basic Access For All Staff:

Main Entry Inner and Outer Door

Employee Main Hallway

LRC Room 124

Main Patio Door

HR Hallway Door to Admin

Courtyard Gate

Emp Lounge Courtyard Door

Emp Lounge North & South

Parking Lot Gate

R/C Doors & Elevator

Access-Assessment Entrance

NW Gym

Women's Lounge to Access

Men's Wing North

Men's Wing East

Adol/YA Patio Doors

Indicate Any Additional Access Required
Will this Staff be driving a company vehicle?*
IT System Access*

*All Avatar users need to be added to the Clinical Email Users distribution list

Email Distribution Lists*
CC Inbox Email Groups*
Does this user need the ability to send an All Staff email?*
Use your mouse or finger to draw your signature above

HR Verify

HR Verify
*If no, contact submitting party to discuss. Do not submit until you are satisfied with form.
HR Orientation Date (if different from start date)
Please add comments and note any changes you made to the original form here.

IT Verify

IT Verify
*If no, contact submitting party to discuss. Do not submit until you are satisfied with form.
Please add comments and note any changes you made to the original form here.

ESD Verify

ESD Verify
*If no, contact submitting party to discuss. Do not submit until you are satisfied with form.
Please add comments and note any changes you made to the original form here.

Security Officer/Designee Section

EMPLOYEE TO COMPLETE

I understand that I must notify the security officer upon the loss of my prox card and/or keys and that lost or damaged prox cards will be replaced at the cost of $5.00 and lost keys at the cost of $2.00.

Use your mouse or finger to draw your signature above
Date

SECURITY OFFICER/DESIGNEE TO COMPLETE

Prox Card Issued On:
Please add comments and note any changes you made to the original form here.
File
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Date Keys Issued:
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