NEBH Network Password Request Form - CareGroup Portal
NEBH Network Password Request Form - CareGroup Portal
NEBH Network Password Request Form - CareGroup Portal
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125 Parker Hill Ave<br />
Boston, MA 02120<br />
Tel 617-754-5372<br />
Fax 617-754-6789<br />
New England Baptist Hospital<br />
Information Systems<br />
<strong>NEBH</strong> NETWORK PASSWORD REQUEST FORM<br />
USER INFORMATION:<br />
Last Name: First Name: Initial:<br />
Location: Phone No:<br />
Department: Supervisor Name:<br />
Employee No: Position:<br />
Are you a New England Baptist Hospital employee<br />
Yes<br />
No<br />
If yes, Full-time Part-time Temporary Contract end date:<br />
If not, please specify the reasons for this request:<br />
Please enter the company name:<br />
Address:<br />
WHAT IS BEING REQUESTED (Check all that apply):<br />
<strong>NEBH</strong> NT Domain account<br />
CITRIX MetaFrame<br />
Dialup Remote Access<br />
Others<br />
For others, please Specify:<br />
Signature:<br />
Date:<br />
Supervisor Signature:<br />
Please fill out the form above and fax or email it to HIS HELPDESK at<br />
Fax No. 617-754-6703 or nebhisreq@caregroup.harvard.edu<br />
We will contact you within 7 days to pick up your user id and password.<br />
If you have any questions, please contact our helpdesk at X45372.
125 Parker Hill Ave<br />
Boston, MA 02120<br />
Tel 617-7545372<br />
Fax 617-754670<br />
New England Baptist Hospital<br />
Information Systems<br />
USER ID<br />
PASSWORD<br />
PASSWORD SECURITY ACKNOWLEDGEMENT<br />
I understand that password is highly confidential and must not be shared with<br />
other person, except for legitimate business reasons, which have been approved<br />
by the employees' supervisor.<br />
I will take all reasonable precautions to safeguard my password. If I suspect that<br />
my password has been compromised, I will immediately change the password<br />
and report it to IS Department.<br />
The misuse of any password or misuse of information obtained by password<br />
access will be subject to disciplinary action, up to and including discharge from<br />
employment.<br />
Please sign and return it to IS Department.<br />
User Signature: _________________________<br />
Print Name: ____________________________<br />
Date: