DOM UIH Application Security Form

DOM UIH Applications Security Form

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

DOM UIH Applications Security Form

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DOM UIH Security Form

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

Date

Requestor Email Address(Required)

Requestor Full Name

Name of the person for whom you are requesting for

NetID (not UIN) of the person for whom you are requesting for:

Request Type

Section 2: Application Access

Do you want to request Epic access?

Yes

Section 2a: EPIC Applications

Note: Click HERE to download the Epic list of names and their description

Epic Role Requested1:

Epic Role Requested2:

EPIC Credentials(Required)

Note: If the user is a Physician, APRN, Physician Assistant, or Midwife: User must be in ACTIVE status with the MSO. CLICK HERE TO SEE BOT/MSO APPROVAL LIST Please do not submit the form until you have verified that MSO has approved the user.

Section 2b: Clinical Applications

Do you want to assign other applications access to user?

Yes

Note: Click HERE to download the UIH application list of names and their description

Application Access1

For Qgenda access, what NetID should we use to mirror the account ?(Required)

Application Access2

For Qgenda access, what NetID should we use to mirror the account ?(Required)

Application Access3

For Qgenda access, what NetID should we use to mirror the account ?(Required)

Application Access4

For Qgenda access, what NetID should we use to mirror the account ?(Required)

Application Enhancement (This includes all of the "other" miscellaneous apps not normally requested)

Section 3: UIH Drive mapping:

Do you want to assign UIH network drive access to user?

Yes

Folder Path (example: \\d2uicmed\dfs-root\Surgery)

Permission Level

Read Only

Modify

Section 4: Empowers LMS Accounts

UIN of the person that you are requesting for(Required)

LMS Request Type(Required)

Type of LMS request being requested

LMS Request Comments

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

Phone

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DOM UIH Application Security Form

DOM UIH Applications Security Form

DOM UIH Applications Security Form

DOM UIH Security Form

Section 1: General Information

Section 2: Application Access

Section 2a: EPIC Applications

Section 2b: Clinical Applications

Section 3: UIH Drive mapping:

Section 4: Empowers LMS Accounts