Children"s of Alabama - Security Badge Request

Children's of Alabama - Access Request

Welcome to Children's of Alabama. We want to make your arrival as easy as possible. You will need to complete a separate registration form for each individual who will need access to our facilities, security badge or parking access. If you have any questions about registration, please call 205-638-4445 or 205-638-9681.

This form is not used for badge replacement. Badge Replacements are $15, cash or check only. Please email security.access@childrensal.org and tia.bearden@childrensal.org with your name, CHS number, and reason for replacement. You will be contacted by a member of the Security staff via email once your replacement badge is ready for pick up.

This form is required for all new staff or affiliates at Children's to receive your ID badge. If you are not an employee or medical provider and will use our network, the additional Affiliate Form must be complete prior to a your arrival to create a CHS account. Please work with your COA contact to be sure all forms are complete at least one week prior to your arrival at our facility.

This form is not intended for short term visiting observers. Visiting observers will need to register in advance with our HIPAA office, visit https://www.childrensal.org/hipaa-information for details. You will check in at the Information Desk upon arrival to obtain a Visitor's pass.

On-site PALS training no longer requires a permanent badge. Please check in at the Visitors Desk upon arrival to obtain a one-day access sticker.

General Information

Relationship to COA*

Type of Request*

I only need a badge and no other network/data access. (Not valid for employees, students or temps.)I am a new arrival and will need a badge in addition to network/data access.I have a badge that needs to be reactivated with no other changes.I have a badge that is no longer correct for my role.

"Badge Only" access may be requested when there is a valid need for daily entry to secure areas. Only third party external organizations and some UAB staff, can request "Badge Only" access. You will need to correct the form to be able to submit.

Only PIN, photo, vehicle and payment type information can be changed on this form for existing badges.

If your name or contact information has changed, your profile will need to be updated in Infor. You can click here for instructions.
If your role at Children's has changed or specific secure area access is needed, your COA sponsor/contact will need to make the change as instructed on our intranet.

Legal Name*

First NameMiddle NameLast NameSuffix (no period)

Date of Birth*

Date of birth must be accurate to prevent duplicate records in our network

Contact Information

If you are not our employee, please provide your work address as your Primary Street Address.

Primary Address Type*

Primary Street Address*

Street Address

Street Address Line 2

CityState

Zip Code

The following contact information will be used for emergency notifications.

If you have a non-COA work email address, please provide it as your Primary Email Address.

Primary Email Type*

Primary Email Address*

This must be a valid email address so we can contact you.

Secondary Email Type*

Secondary Email Address

Primary Phone Type*

Primary Phone Number*

Secondary Phone Type*

Secondary Phone Number

COA Role Information

Start Date*

End Date if known

Department Name*

Dept Phone Number

Supervisor or COA Contact*

Supervisor or Contact Email Address*

Scheduled Hours Per Week

Scheduled Days Per Week

ID Badge/Org Information

Full Preferred Name

The name you go by

Role or Title*

Role at COA

Clinical Certification/Degree*

NPI Number, If Applicable

Specialty

Sub Specialty

School Attended, if Applicable

MD Student Year, if applicable

Check if you ever previously had access to CoA.

True

Check if you have a badge or parking decal from prior access.

True

School or Organization Sponsor

If applicable, such as affiliate student/intern

Sponsor Email Address

Current or Former COA ID, if known

Choose a PIN for Secure Area Access*

4 digits

Briefly describe your role at Children's to help us determine appropriate badge access.*

0/500

New arrivals must submit a photo with this request. If you already have a badge and noted that above, no photo is required. If you are completing the form for someone else and no photo is available, enter your email address below.

Option 1: Please attach a picture of your face in one of these formats: bmp, pdf, gif, jpeg, jpg. Image sizes of approximately 150 x 200 work best. Limit 5 mg in file size.

Option 2: Take a photo - Must be low resolution or cropped to face only, limit 5 mg.

Option 3: If you are completing this form for someone else and no photo is available, enter your email here. The photo must be emailed to security.access@childrensal.org for a badge to be created.

example@example.com

Vehicle Information

Payroll deduction option is only available to employees who are on the Children's of AL payroll. This is not an option for employees of UAB or any other organization. All non-Children's employees will be required to pay by check.

The following fields are needed for all employees or affiliates who will need to use staff parking.*

I will need to use staff parking at CoAI choose to opt out of staff parking at CoA

1st Vehicle Make

1st Vehicle Model

1st Vehicle Year

1st Vehicle Color

1st Vehicle Tag Number

2nd Vehicle Make

2nd Vehicle Model

2nd Vehicle Year

2nd Vehicle Color

2nd Vehicle Tag Number

Parking Payment Method (payroll option available only for direct COA employees)*

PayrollCheck

Please note, you will need to be connected to the internet to submit this form from a device.

Admin Note

The submit button will not display until all required fields have been updated.