Nursing Information System Access Request Form
Request access to the nursing information system by providing your work details, requested permissions, and manager approval information.
Requester Information
Full Name
*
First Name
Middle Name
Last Name
Work Email
*
example@example.com
Work Phone or Extension
Organization / Facility Name
*
Department / Unit
*
Job Role / Title
*
Access Request Details
Nursing Information System / Application
*
Please Select
Epic
Cerner
MEDITECH
Allscripts
Other
Requested Module or Area of Access
*
Patient Charting
Medication Administration
Care Plans
Orders & Results
Scheduling & Staffing
Clinical Documentation
Reporting & Analytics
Other
Access Level Requested
*
View Only
Standard User
Edit
Supervisor
Administrator
Other
Reason for Access
*
Requested Access Start Date
*
 -
Month
 -
Day
Year
Date
Expected Duration or End Date
Urgency / Priority
*
Routine
Urgent
Critical
Other
Specific Permissions Needed
Manager or Supervisor Approval
Approver Name
*
First Name
Last Name
Approver Job Title
*
Approver Email
*
example@example.com
Approval Status
*
Approved
Pending
Needs Review
Denied
Approval Comments or Justification
Operational Notes
Additional Notes or Instructions
Preferred Onboarding or Access Training Date/Time
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Confirmation of Access Scope Understanding
*
I understand access is limited to authorized job duties only
Submit Request
Should be Empty: