ID Badge Form for Clinical Instructors
Last Name:		
First Name:		
Middle Name:		
Dept. Name:		
Job Title:  	Clinical Instructor 	
Employee #:  	Not Applicable	
Card #:		
Badge Color:		
Access Level#:		
FIT TEST:	□ Small    □ Regular   □ N/A	

Reason for Request:
[x] New [x]Other: Clinical Instructor
□ New Employee   □ Medical Staff
□ Volunteer           □ Student
□ New Job Title/Department
□ Name Change
□ Lost ($6.00 Fee for Replacement)
□ Broken/Faded/Inoperable

Comments: _________________________________________________

College/University: _________________ Unit Assigned: ______________ 

Clinical Rotation: Starts: ____/____/______   Ends: ____/____/______     

Clinical Instructor needs access to the assigned Unit’s:
[x] Clean/Dirty Utility [x] Medication Room [x] Staff Lounge

Authorized by:  _____________________________________
                                                          Director of Nursing Education 4724
                                             or designated Nursing Professional Development Specialist