Forms

Requesting Access for an Intern

Disclaimer 1:

New AD user account requests require the completion of HIPAA Privacy and Information Security training. If the training is not completed at the time this request is submitted, AD account establishment will be significantly delayed. CITI HIPAA certificates are not acceptable under UCLA Health. Please ask user to visit the following link to complete the UCLA HIPAA training as soon as possible: https://uclahs.fyi/HIPAAtrainingOCR

Disclaimer 2:

For an intern role with Semel Institute, user must be enrolled as a student in a non-UC campus and needs AD access to participate in training or internship.

Acknowledgements:

Attention!

Applying for mednet vpn access?

Only supervisors/managers should complete this form!

Click here to proceed

Attention!

Applying for access request with no UCPath appointment?

Enter user's name.

Please SELECT ONE of the categories below that the user belongs to.

Note: If none of these apply to you, then you should not fill out this form.

For a definition of each category, hover over here!
CATEGORY DEFINITION
Affiliate A student or staff in non-UCLA Health department.
Contractor Meets BFB-BUS-77 Independent Consultant Guidelines https://policy.ucop.edu/doc/3220485/BFB-BUS-43 https://policy.ucop.edu/doc/3600670/Independent Contractor
Collaborator User who is a student or staff in other universities and is part of an IRB.
Intern User is not enrolled in any UC campus as student. Need access to participate in training or internship.
Volunteer Registered with UCLA Health Sciences Volunteer Program https://www.uclahealth.org/volunteer/ucla-health-sciences-volunteer-program

just making sure you're not a robot

Attention!

Applying for Research careconnect access?

Please contact Semel Research CareConnect at SemelResCon@mednet.ucla.edu.