User Access Request Form

Use this form when requesting additional access to the Colleague System or when requesting access for a new user. Questions can be directed to Mary Aumann at x7135. All access requests are subject to your supervisor's approval.

Enter your full name in the space provided below.

Enter your full e-mail address below.

Colleague ID Number:

Enter the date:
- mm/dd/yy

Enter your department name.

Enter your phone number.

Are you a new user?
Yes No

Access to Query Builder? (Requires signing Query Access Policy Form)
Yes No     Reason:

Access to view social security numbers?
Yes No     Reason:

Access to view birthdates?
Yes No     Reason:

Enter the mnemonic(s) you need access to.

Enter the date needed by.
- mm/dd/yy

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