Affiliated Student Group HealthConnect™ Fresno, California & Security Identification Request (Confidential) Winter Spring School Academic Year Semester Summer Fall Course Rotation at Kaiser Permanente For Security CCPS# Start End Dept Mon Tue Wed Thu Fri Days Instructor Cell # Mgr Sat Sun Hours Home # School # Title Military Time (e.g., 0800-1400) Completed by Medical Center KPHC Temp Last Name First Name DOB SSN # Lic Plate # Gender Signature for ID* NUID Y/N Password (typewritten) (typewritten) (mm/dd/yy) (typewritten) (typewritten) (M/F) (Signed Upon Issuance ) 1 2 badge) 3 release 4 not student do 5 6 checked previous (If 7 or 8 checkbox 9 Employee KP 10 Release 11 Badge 12 Completed by school Completed by Medical Center Instructor Signature (ID Received**) *The Photo Identification Badge is to be worn at all times while the person is at work on Kaiser Permanente property and is to be displayed on the upper torso. The badge remains the property of Kaiser Permanente Medical Center and is to be returned to Security Services upon transfer, termination or completion of your clinical rotation. **By signing, you are indicating you received ID badge(s) for students listed on this roster and that you will be responsible for ensuring they are returned to Security Services or Clinical Education at the end of their clinical rotation as specified above
Fresno, California Affiliated Student Group HealthConnect™ & Security Identification Request (Confidential) School Academic Year Semester Winter Spring Summer Fall Course Rotation at Kaiser Permanente For Security CCPS# Start End Dept Instructor Cell # Days Mon Tue Wed Thu Fri Sat Sun Mgr Home # School # Hours Title Military Time (e.g., 0800-1400) Completed by Medical Center Last Name (typewritten) First Name (typewritten) DOB (mm/dd/yy) SSN # (typewritten) Lic Plate # (typewritten) Gender (M/F) Y/N Signature for ID* (Signed Upon Issuance ) NUID KPHC Temp Password 1 KP Employee or previous student Badge Release checkbox (If checked do not release badge) 2 3 4 5 6 7 8 9 10 11 12 Completed by school Completed by Medical Center Instructor Signature (ID Received**) *The Photo Identification Badge is to be worn at all times while the person is at work on Kaiser Permanente property and is to be displayed on the upper torso. The badge remains the property of Kaiser Permanente Medical Center and is to be returned to Security Services upon transfer, termination or completion of your clinical rotation. **By signing, you are indicating you received ID badge(s) for students listed on this roster and that you will be responsible for ensuring they are returned to Security Services or Clinical Education at the end of their clinical rotation as specified above