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iamdev.sidium.cloud Open in urlscan Pro
52.177.165.233  Public Scan

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URL: https://iamdev.sidium.cloud/
Submission: On February 24 via api from US — Scanned from US

Form analysis 1 forms found in the DOM

Name: helpform — POST https://iamdev.sidium.cloud/account/store

<form method="post" action="https://iamdev.sidium.cloud/account/store" id="helpform" name="helpform" enctype="multipart/form-data">
  <input type="hidden" name="_token" value="FcwKMUw8gR0pbkQynsob0VBWQDOpUpJo1oJn56pj">
  <h4><strong>Request Information</strong></h4>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label for="type">Request Type</label>
      <select name="request_type" id="request_type" class="form-control" required="">
        <option value="">Please Select One...</option>
        <option value="New_User">New User</option>
        <option vlaue="Access_Change">Access Change</option>
        <option value="Termination">Termination</option>
      </select>
    </div>
    <div class="form-group col-md-4">
      <label for="type">Date Needed</label>
      <input type="date" name="date_needed" id="date_needed" class="form-control" value="" required="">
    </div>
    <div class="form-group col-md-4">
      <label for="type">Termination Date<span class="required_star" style="color:red;"></span></label>
      <input type="date" name="termination_date" id="termination_date" class="form-control" value="">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-6">
      <label for="iks_request">Vendor</label>
      <select name="iks_request" class="form-control">
        <option value="N">No</option>
        <option value="IKS">IKS</option>
        <option value="OClinicals">OClinicals</option>
        <option value="GeBBS">GeBBS</option>
        <option value="TCN">TCN</option>
      </select>
    </div>
    <div class="form-group col-md-6">
      <label for="iks_form">IKS Form</label>
      <input type="file" class="form-control" name="iks_form">
    </div>
  </div>
  <hr>
  <h4><strong>Requester Information</strong></h4>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label for="#">Last Name</label>
      <input type="text" name="requester_last_name" id="" class="form-control" value="" required="">
    </div>
    <div class="form-group col-md-4">
      <label for="#">First Name</label>
      <input type="text" name="requester_first_name" id="" class="form-control" value="" required="">
    </div>
    <div class="form-group col-md-4">
      <label for="#">Title</label>
      <input type="text" name="requester_title" id="" class="form-control" value="" required="">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>Email</label>
      <input type="email" name="requester_email" id="" class="form-control" value="" required="">
    </div>
    <div class="form-group col-md-4">
      <label>Phone</label>
      <input type="text" name="requester_phone" id="phone" class="form-control" value="" required="">
    </div>
    <div class="form-group col-md-4">
      <label>Department</label>
      <input type="text" name="requester_department" id="department" class="form-control" value="" required="">
    </div>
  </div>
  <hr>
  <h4><strong>Personal Information</strong></h4>
  <div class="form-row">
    <div class="form-group col-md-3">
      <label>Legal Last Name</label>
      <input type="text" name="personal_last_name" id="last_name" class="form-control" value="">
    </div>
    <div class="form-group col-md-3">
      <label>Middle Initial</label>
      <input type="text" name="personal_middle_initial" id="last_name" class="form-control" value="">
    </div>
    <div class="form-group col-md-3">
      <label>Legal First Name</label>
      <input type="text" name="personal_first_name" id="last_name" class="form-control" value="">
    </div>
    <div class="form-group col-md-3">
      <label for="exemption_type">Exempt?</label>
      <select name="exemption_type" class="form-control">
        <option value=""></option>
        <option value="Exempt">Exempt</option>
        <option value="Non_Exempt">Non-Exempt</option>
      </select>
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>Job Title</label>
      <input type="text" name="secondary_title" id="last_name" class="form-control" value="">
    </div>
    <div class="form-group col-md-4">
      <label>Department</label>
      <input type="text" name="personal_department" id="personal_department" class="form-control" value="">
    </div>
    <div class="form-group col-md-4">
      <label>Mobile Phone - If MDM access is required</label>
      <input type="tel" name="mdm_phone" id="mdm_phone" class="form-control" value="" im-insert="true">
    </div>
  </div>
  <hr>
  <h4><strong>USDH Work Location</strong></h4>
  <div class="form-row">
    <div class="form-group col-md-5">
      <label for="address">Address</label>
      <input type="text" name="address" id="address" class="form-control" value="" required="">
    </div>
    <div class="form-group col-md-3">
      <label for="city">City</label>
      <input type="text" name="city" id="city" class="form-control" value="" required="">
    </div>
    <div class="form-group col-md-2">
      <label for="state">State</label>
      <select name="state" id="state" class="form-control">
        <option value="AL">Alabama</option>
        <option value="AK">Alaska</option>
        <option value="AZ">Arizona</option>
        <option value="AR">Arkansas</option>
        <option value="CA">California</option>
        <option value="CO">Colorado</option>
        <option value="CT">Connecticut</option>
        <option value="DE">Delaware</option>
        <option value="DC">District Of Columbia</option>
        <option value="FL">Florida</option>
        <option value="GA">Georgia</option>
        <option value="HI">Hawaii</option>
        <option value="ID">Idaho</option>
        <option value="IL">Illinois</option>
        <option value="IN">Indiana</option>
        <option value="IA">Iowa</option>
        <option value="KS">Kansas</option>
        <option value="KY">Kentucky</option>
        <option value="LA">Louisiana</option>
        <option value="ME">Maine</option>
        <option value="MD">Maryland</option>
        <option value="MA">Massachusetts</option>
        <option value="MI">Michigan</option>
        <option value="MN">Minnesota</option>
        <option value="MS">Mississippi</option>
        <option value="MO">Missouri</option>
        <option value="MT">Montana</option>
        <option value="NE">Nebraska</option>
        <option value="NV">Nevada</option>
        <option value="NH">New Hampshire</option>
        <option value="NJ">New Jersey</option>
        <option value="NM">New Mexico</option>
        <option value="NY">New York</option>
        <option value="NC">North Carolina</option>
        <option value="ND">North Dakota</option>
        <option value="OH">Ohio</option>
        <option value="OK">Oklahoma</option>
        <option value="OR">Oregon</option>
        <option value="PA" selected="">Pennsylvania</option>
        <option value="RI">Rhode Island</option>
        <option value="SC">South Carolina</option>
        <option value="SD">South Dakota</option>
        <option value="TN">Tennessee</option>
        <option value="TX">Texas</option>
        <option value="UT">Utah</option>
        <option value="VT">Vermont</option>
        <option value="VA">Virginia</option>
        <option value="WA">Washington</option>
        <option value="WV">West Virginia</option>
        <option value="WI">Wisconsin</option>
        <option value="WY">Wyoming</option>
      </select>
    </div>
    <div class="form-group col-md-2">
      <label for="zipcode">Zipcode</label>
      <input type="text" name="zipcode" id="zipcode" class="form-control" value="" required="">
    </div>
  </div>
  <hr>
  <h4><strong>Computer Access Information</strong></h4>
  <div class="form-row">
    <div class="form-group col-md-6">
      <h5>Network Account (USDH)</h5>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="ptsn_audio_conferencing">
        <label class="form-check-label" for="defaultCheck1"> MS Teams Audio Conferencing (Host Access) </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="mdm_access" name="mdm_access">
        <label class="form-check-label" for="defaultCheck1"> Mobile Device Management - (Phone Email Access) </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="m365_local_install">
        <label class="form-check-label" for="defaultCheck1"> Microsoft 365 - Local Computer Install </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="m365_business_basic">
        <label class="form-check-label" for="defaultCheck1"> Microsoft 365 - Business Basic - Web Email and Web Office </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="remote_access">
        <label class="form-check-label" for="defaultCheck1"> Remote Access </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="is_provider">
        <label class="form-check-label" for="defaultCheck1"> Remote user is Provider </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="local_access">
        <label class="form-check-label" for="defaultCheck1"> Local Access (Shared Drive, Hospital) </label>
        <input type="text" name="local_access_info" class="form-control" value="">
      </div>
      <div class="form-check ml-3 pt-1">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="iks_dashboard">
        <label class="form-check-label" for="defaultCheck1"> Dashboard </label>
      </div>
      <br>
      <div class="ml-3">
        <label><strong>Same Access As:</strong></label>
        <input type="text" name="same_access_as" id="last_name" class="form-control" value="">
      </div>
      <br>
      <h5><strong>EMR Access</strong></h5>
      <div class="div">
        <div class="row">
          <div class="col-md-6">
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="allscripts">
              <label class="form-check-label" for="defaultCheck1"> Allscripts </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="pm">
              <label class="form-check-label" for="defaultCheck1"> PM </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="ehr">
              <label class="form-check-label" for="defaultCheck1"> EHR </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="medent">
              <label class="form-check-label" for="defaultCheck1"> Medent </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="ecw">
              <label class="form-check-label" for="defaultCheck1"> eCW </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="epic">
              <label class="form-check-label" for="defaultCheck1"> Epic </label>
            </div>
          </div>
          <div class="col-md-6">
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="centricity">
              <label class="form-check-label" for="defaultCheck1"> Centricity </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="ggastro">
              <label class="form-check-label" for="defaultCheck1"> gGastro </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="sage_intacct">
              <label class="form-check-label" for="defaultCheck1"> Sage Intacct </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="vital_axis">
              <label class="form-check-label" for="defaultCheck1"> VItal Axis (Path LIS) </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="remote_scan">
              <label class="form-check-label" for="defaultCheck1"> Remote Scan </label>
            </div>
            <div class="form-check ml-3">
              <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="ehr_na">
              <label class="form-check-label" for="defaultCheck1"> N/A </label>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="form-group col-md-6 px-5">
      <h5>Termination<span class="required_star" style="color:red;"></span></h5>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="disable_all_accounts">
        <label class="form-check-label" for="defaultCheck1"> Disable All Accounts </label>
      </div>
      <br>
      <h5>Extend Email Retention<span class="required_star" style="color:red;"></span></h5>
      <!--
                <div class="form-check ml-3">
                    <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="legal_hold_email" >
                    <label class="form-check-label" for="defaultCheck1">
                        Email
                    </label>
                </div>
                <div class="form-check ml-3">
                    <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="legal_hold_one_drive" >
                    <label class="form-check-label" for="defaultCheck1">
                        One Drive
                    </label>
                </div>
                <div class="form-check ml-3">
                    <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="legal_hold_na" >
                    <label class="form-check-label" for="defaultCheck1">
                        N/A
                    </label>
                </div>
                -->
      <select name="extend_email_hold" class="form-control">
        <option value="No">No</option>
        <option value="Yes">Yes</option>
      </select>
      <br>
      <h5>Voicemail Forward</h5>
      <label><strong>To:</strong></label>
      <input type="text" name="voicemail_name" id="last_name" class="form-control" value="">
      <label><strong>Phone Number:</strong></label>
      <input type="text" name="voicemail_phone" id="voicemail_phone" class="form-control" value="" im-insert="true">
      <br>
      <h5>Grant Delegation<span class="required_star" style="color:red;"></span></h5>
      <label><strong>To:</strong></label>
      <input type="text" name="delegation_last_name" id="last_name" class="form-control" value="">
      <br>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="delegation_email">
        <label class="form-check-label" for="defaultCheck1"> Email </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="delegation_calendar">
        <label class="form-check-label" for="defaultCheck1"> Calendar </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="delegation_one_drive">
        <label class="form-check-label" for="defaultCheck1"> One Drive </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="delegation_na">
        <label class="form-check-label" for="defaultCheck1"> N/A </label>
      </div>
    </div>
  </div>
  <hr>
  <h4>Hardware/Software</h4>
  <div class="row">
    <div class="col-md-6">
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="laptop">
        <label class="form-check-label" for="defaultCheck1"> New Laptop </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="laptop_old">
        <label class="form-check-label" for="defaultCheck1"> Repurpose Laptop </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="desktop">
        <label class="form-check-label" for="defaultCheck1"> New Desktop </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="desktop_old">
        <label class="form-check-label" for="defaultCheck1"> Repurpose Desktop </label>
      </div>
    </div>
    <div class="col-md-6">
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="monitor">
        <label class="form-check-label" for="defaultCheck1"> Monitor </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="dual_monitor">
        <label class="form-check-label" for="defaultCheck1"> Dual Monitor </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="docking_station">
        <label class="form-check-label" for="defaultCheck1"> Docking Station </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="ring_central">
        <label class="form-check-label" for="defaultCheck1"> Ring Central </label>
      </div>
      <div class="form-check ml-3">
        <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="ring_central_max">
        <label class="form-check-label" for="defaultCheck1"> Ring Central Max Agent </label>
      </div>
    </div>
  </div>
  <div class="form-check ml-3">
    <input class="form-check-input" type="checkbox" value="Y" id="defaultCheck1" name="other_hardware_software">
    <label class="form-check-label" for="defaultCheck1"> Other Hardware/Software </label>
    <input type="text" name="other_hardware" class="form-control" value="">
  </div>
  <hr>
  <h4><strong>Additional Information</strong></h4>
  <div class="form-row">
    <div class="form-group col-md-12">
      <textarea name="additional_information" id="" rows="10" class="form-control"></textarea>
    </div>
  </div>
  <button type="submit" class="btn btn-primary" onclick="this.form.submit(); this.disabled=true; this.value='Sending…'; ">Submit</button>
</form>

Text Content

IDENTITY ACCESS MANAGEMENT

This form should be completed and submitted 5 days before a new employee begins
working or tranfers to a new department. NOTE: HR will manage registration for
Paylocity and HealthStream and other HR-related systems.

NOTE: If you do not see your service listed, please type it in the Additional
Information section.

REQUEST INFORMATION

Request Type Please Select One... New User Access Change Termination
Date Needed
Termination Date
Vendor No IKS OClinicals GeBBS TCN
IKS Form

--------------------------------------------------------------------------------

REQUESTER INFORMATION

Last Name
First Name
Title
Email
Phone
Department

--------------------------------------------------------------------------------

PERSONAL INFORMATION

Legal Last Name
Middle Initial
Legal First Name
Exempt? Exempt Non-Exempt
Job Title
Department
Mobile Phone - If MDM access is required

--------------------------------------------------------------------------------

USDH WORK LOCATION

Address
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware
District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas
Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi
Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York
North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West
Virginia Wisconsin Wyoming
Zipcode

--------------------------------------------------------------------------------

COMPUTER ACCESS INFORMATION

NETWORK ACCOUNT (USDH)

MS Teams Audio Conferencing (Host Access)
Mobile Device Management - (Phone Email Access)
Microsoft 365 - Local Computer Install
Microsoft 365 - Business Basic - Web Email and Web Office
Remote Access
Remote user is Provider
Local Access (Shared Drive, Hospital)
Dashboard

Same Access As:


EMR ACCESS

Allscripts
PM
EHR
Medent
eCW
Epic
Centricity
gGastro
Sage Intacct
VItal Axis (Path LIS)
Remote Scan
N/A

TERMINATION

Disable All Accounts


EXTEND EMAIL RETENTION

No Yes


VOICEMAIL FORWARD

To: Phone Number:


GRANT DELEGATION

To:

Email
Calendar
One Drive
N/A

--------------------------------------------------------------------------------

HARDWARE/SOFTWARE

New Laptop
Repurpose Laptop
New Desktop
Repurpose Desktop
Monitor
Dual Monitor
Docking Station
Ring Central
Ring Central Max Agent
Other Hardware/Software

--------------------------------------------------------------------------------

ADDITIONAL INFORMATION


Submit