Intern / Resident / Shadow Status Form

What type of Status: New

Select every site where badge access is required.

Select an Area of Business, then choose a Sub-Account from that area's list, and the % of salary charged to it. Percentages must total 100%.

Required — type your name, sign, and certify before submitting.

This request routes to the Clinical Supervisor, then to Avery as final approver. You'll see who was assigned after you submit.

For record-keeping only — approval routing and CC are handled automatically.