Your browser is unsupported

We recommend using the latest version of IE11, Edge, Chrome, Firefox or Safari.

Search

Department of Medicine

UI Health is UIC’s academic health enterprise
View Menu Down arrow icon

DOM UIH Application Security Form

UIC's DOM IT image

This form is to be used by authorized Department of Medicine staff and faculty to request security access for their staff. Please email domit@uic.edu if you have any questions on how to fill out the form.

Please make sure to check with the UIH Helpdesk at 312-413-7717 before you submit any requests to ensure that the user has been approved by the Board of Directors or that they don’t already have the access that you are requesting.

DOM UIH Security Form (Ver 15.0)

Please click on the SUBMIT button at the bottom of the page to submit the form to your IT team for processing.

Section 1: General Information

MM slash DD slash YYYY

Section 2: EPIC Applications

Section 3: Clinical Applications

Other systems

UIH Drive mapping: (Shared folder(s) will appear under the Shared (O:) network drive.)

Permission Level

Press the SUBMIT button below to email your form to the DOM IT team for processing.