VCUHS VCUCard Policy - Student Advantage

VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM
MEDICAL COLLEGE OF VIRGINIA HOSPITALS AND PHYSICIANS
POLICY AND PROCEDURE MANUAL
SUBJECT POLICY NO: 2130.00
APPROVED DATE: 9/18/00
IDENTIFICATION BADGES EFFECTIVE DATE: 9/18/00
REVIEWED DATE: 8/24/00
SUPERSEDES NO:
NEW
I. PURPOSE:
To provide for identification of persons authorized to have access to
MCV Hospitals and Physicians (MCVH&P) and to provide a method for
patients, Visitors, and Staff to identify individuals, including their
role, when provided with customer service at MCVH&P.
II.
III.
POLICY:
All Staff who represent the Virginia Commonwealth University Health
System (VCUHS) to the public or who are participating in an educational
program at MCV Hospitals and Physicians are required to wear an
identification (ID) badge while performing that role at the facilities.
Staff providing patient care services must wear an ID badge displaying
their name and job title.
DEFINITIONS:
For purposes of this policy, the following definitions shall apply.
Authorizing Agent – Individuals authorized by Department Manager or
Director to complete Non-Employee Information (NEI) forms in
Sponsoring Departments.
Contract Staff – Those individuals who provide direct services to VCU
Health System customers at an MCVH&P facility through a
contractual agreement.
Employee –All persons employed by MCVH&P.
Housestaff – Employees of MCVH&P including residents, interns, fellows
and trainees of graduate education programs.
Non-Employee – Contractors, Volunteers, Physicians, Staff supplied by
agencies other than MCVH&P, Students, etc. that provide goods or
services to VCU Health System customers or participate in an
educational experience provided by MCVH&P.
Physician/Dentist – Individuals licensed by the State of Virginia to
practice medicine (or osteopathic medicine) or dentistry.
Physicians/dentists must be granted privileges by the Chief of
the Medical Staff prior to practice at MCVH&P.
Practitioner – Any individual certified or licensed by any of the
health regulatory boards with the Department of Health
Professions, except Staff regulated by the Board of Funeral
Directors and Embalmers or the Board of Veterinary Medicine.

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IDENTIFICATION BADGES
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Sponsoring Department – The department responsible for providing
authorization for an individual to have access to MCVH&P
facilities. For example, Human Resources for Employees,
Volunteer Services Department for Volunteers, the department
purchasing a service from contractors, the department agreeing to
provide an educational experience, etc.
Staff – Employees and Non-Employees as defined in this policy.
Student – An individual enrolled in a school, college, university or
organized training program authorized to provide services or
participate in an educational program at VCU Health Systems.
VCUCard – Official picture ID card used by Virginia Commonwealth
University, MCV Hospitals and MCV Physicians.
Vendor – An individual who sells or provides goods or services to the
VCU Health System and whose access to MCVH&P facilities is
limited. (See policy 7202.02, Hospital Vendor Policy)
Visitor –Individuals who receive goods or services, deliver goods or
services, or meet with Staff who provide goods or services for
the VCU Health System.
Volunteer – An individual who provides help or services to VCU Health
System without compensation through the Volunteer Services
Department.
IV.
PROCEDURE:
A. ID Badge Requirements
1. All Staff who will be providing services to MCVH&P
customers or who will be participating in an educational
process requiring access to MCVH&P must wear a MCVH&P
issued badge.
2. Staff who require access to MCVH&P facilities for greater
than one continuous calendar week will be issued ID badges
displaying the individual’s name, job title, department and
picture.
3. Staff with short-term assignments expected to last less
than one week will be issued special badges displaying the
name of the Sponsoring Department. These Staff must also
wear a badge or nametag displaying their name and job
title. Use of a picture ID is preferable but not
mandatory.
4. ID badges should be obtained on the first day of employment
or long term assignment to an MCVH&P facility. Special
short-term badges (see section IV.A.3) must be used to
identify authorization to an area until a picture ID can be
obtained.
5. ID badges will be displayed with picture side face out and
worn in full view on the front and upper portion of the
body.

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IDENTIFICATION BADGES
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6. ID badges may be used to obtain access to MCVH&P facilities
and specific department areas with authorization. (See
hospital policy 7200.03, Access to Hospital Areas or
Facilities.)
7. Staff who perform two or more roles at VCU Health System
need a separate ID for each significantly different role.
For example: An Employee who is also a Student in a
clinical rotation at MCVH&P should be issued an ID for each
role. An Employee who has a second job at MCVH&P should
have a separate ID for each position.
a. Staff will be issued a primary ID for MCVH&P
employment or if not employed at MCVH&P, the role,
which they spend the majority of their time
performing for the organization.
b. Primary IDs will consist of the individual’s picture,
name, job title, department name, and bar code (if
applicable) on the front and an access strip on the
back.
c. Secondary IDs will be issued for each subsequent role
and will consist of the individual’s picture, name,
job title, and department name on the front. The back
of the card will be blank.
d. Staff are responsible for displaying the appropriate
ID badge for the role they are in the process of
performing.
e. Access required for each role will be programmed to
the primary ID badge.
f. Staff are responsible returning ID badges to their
managers when their role in that area is complete.
g. Managers are responsible for cancellation of specific
access areas when a staff member is no longer
authorized to be in that area and for the return of
ID card(s) to the VCUCard office when staff roles are
no longer valid.
8. Defacing an ID badge is prohibited. (i.e., stickers, pins,
etc.). Stickers or pins attached to badge holders must not
obstruct the picture or identifying information on the
badge.
9. Staff are responsible for replacement of an ID badge if
defaced, lost or missing. Replacement cost is the
responsibility of the individual unless otherwise specified
within this policy.
10. Unauthorized possession, use, or reproduction of a VCUCard
may constitute theft or misappropriation of VCU Health
System property and will be grounds for disciplinary action
up to and including termination of employment or
prosecution by law.
11. The department manager/designee is responsible for
monitoring and enforcement of section IV.A. Staff who
report to work without their ID badge may be required to
make a round trip home without pay to obtain their ID
badge.

POLICY NO.: 2130.00
IDENTIFICATION BADGES
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B. Non-Employee Information Form Completion and Identity
Verification Process
1. The Sponsoring Department must complete a “Non-Employee
Information” (NEI) form for all Non-Employees whose role
will require access to MCVH&P facilities for more than one
week. Employee information will be obtained by Human
Resources.
2. Sponsoring Departments must designate a limited number of
Staff from their department to complete NEI forms and act
as Authorizing Agents in regard to information submitted.
3. MCVH Human Resources will maintain the list of Authorizing
Agents and provide a copy to VCUCard office to use for reissuing
lost ID badges.
4. NEI forms must be emailed or faxed to MCVH Human Resources,
Transactions prior to ID badges being issued.
5. The Sponsoring Department or Human Resources is responsible
for verifying the identity of Staff whom they authorize to
have access to MCVH&P facilities prior to an ID being
issued. Sponsoring Departments may establish a contact at
affiliated schools to complete the NEI forms and provide a
copy of identity confirmation documents in advance for
Student groups who will have an instructor in attendance
while at MCVH&P.
6. Staff must present one of the following original documents
to the Sponsoring Department or Human Resources for
identification verification:
a. a passport displaying the individual’s picture
b. a driver’s license displaying the individual’s
picture
c. a state or federal issued identification card
displaying the individual’s picture and other
identifying information such as sex, race, height,
eye color, birth date, or similar detail
7. Human Resources will enter NEI information and transmit it
electronically to VCUCard for confirmation of
authorization. Data which has been received by Human
Resources but not electronically transmitted to the VCUCard
office prior to the individual’s arrival to obtain an ID
may be confirmed between Human Resources and VCUCard in an
alternate method acceptable to both.
8. VCUCard will transmit Employee and Non-Employee data to
MCVH&P Security upon assignment of a badge number.
C. Special Short-Term Badge Use
1. Non-Employees who will need access to MCVH&P facilities for
less than one continuous week will be issued a special
badge to identify their access authorization. Staff who
will have customer contact must also display a separate ID
consisting of their name and job title. A picture ID is
preferable.
2. The Sponsoring Department must verify identification for
Staff whose assignment is expected to be less than one week
in duration per IV.B.5-6.

POLICY NO.: 2130.00
IDENTIFICATION BADGES
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3. Upon request to the VCUCard office, Sponsoring Departments
who have Staff with short-term assignments may be issued a
specific number of special badges. Badges may be tailored
to include job title or role identification. A charge by
VCUCard may be incurred by departments for these badges.
4. Sponsoring Departments should number special badges and
keep a log of who was issued which numbered badge to assist
in monitoring return of badges. Sponsoring Departments are
solely responsible for monitoring the distribution and
return of special short-term badges.
D. Issuing Picture ID
1. When a Staff member arrives at the VCUCard office
requesting an ID, VCUCard staff must first verify
authorization for the individual to have an ID.
2. Authorization verification, in most cases, will be via the
electronic database provided by Human Resources. However,
if the information is not in the database, VCUCard will
contact Human Resources directly for confirmation.
3. In addition, one form of identity verification as noted in
section IV.B.6 must be presented to the VCUCard office
before an ID can be issued.
E. Access to Facilities
1. Staff access to facilities will be based on work location
and job duties. Department managers may request specific
access by contacting the MCVH Safety and Security office.
(See Policy 7200.03, Access to Hospital Areas or
Facilities.)
2. MCVH Safety and Security office must be notified
immediately by the department manager to cancel access
whenever a Staff member is involuntary separated or a badge
is lost.
F. Lost Badges
1. Lost or missing badges must be reported to MCVH Safety and
Security office and the VCUCard Office to cancel facility
access and authorize re-issuance of an ID badge.
2. Prior to Staff receiving a replacement ID, the Sponsoring
Department must provide authorization for replacement to
the VCUCard office. Notification of authorization must be
by email (VCUCard@aspen.vcu.edu) or fax (828-8855). The
VCUCard office will call the Sponsoring Department’s
Authorizing Agent to verify that the request for
replacement is legitimate.
3. A replacement fee will be charged for lost or damaged ID
badges.
4. A picture ID as specified in IV.B.6 must be presented at
the VCUCard office prior to a replacement ID being issued.
5. If a lost ID badge is found after a new badge is issued,
the individual must return the old badge to the VCUCard
office.

POLICY NO.: 2130.00
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G. Renewal of ID Active Status
1. Employee active status and access to facilities will be
maintained by Human Resources and communicated
electronically to the VCUCard office.
2. Non-Employee active status for the ID badge and access to
facilities will be discontinued based on the access
expiration date noted on the NEI form. If no expiration
date is indicated on the form, Staff access will be
discontinued one year from their start date or upon
separation notification to Human Resources.
3. Human Resources will submit an expiration report quarterly
to affected departments identifying Non-Employee’s whose
access will expire the following quarter.
4. Sponsoring Departments are responsible for submitting a
revised NEI form to Human Resources prior to the access
expiration date or annually based on the start date.
5. Forms not received by the access expiration date noted on
the NEI form will result in the Staff member’s access being
cancelled.
6. A replacement fee may be charged to Sponsoring Departments
who fail to submit the renewal request to Human Resources
in a timely manner resulting in a new ID being issued.
H. Separations
1. The Sponsoring Department must notify MCVH Human Resources
of all separations no later than 24 hours after separation.
2. The VCUCard office and MCVH Safety and Security office must
be notified immediately by email or fax to delete access
for all involuntary separations.
3. Staff must return ID badges to the Sponsoring Department
upon department transfer or separation.
4. The Sponsoring Department is responsible for returning ID
badges to the VCUCard office.
V. References:
State Laws:
• Virginia Board of Nursing, title of Regulations: 18 VAC 95-20-35
• Code of Virginia, §46.2-345.H
Rules and Regulations:
• Joint Commission for Accreditation of Health Care Organizations
Policies and Procedures
• Policy 7202.02, Hospital Vendor Policy
• Policy, 7200.03, Access to Hospital Areas or Facilities
• Policy, 7201.00, Inpatient Visitation
• MCVP Policy 493.00, Identification Badges
• MCVP Policy 112.00, Access to MCV Associated Physicians’ Facilities
VI. Resources:
• MCVH Human Resources 628-4748
• MCVH Safety and Security Office 828-6595
POLICY NO.: 2130.00
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• VCUCard Office 828-0522
• MCVP Human Resources 342-1382
APPROVED BY:
_________________________________________
Hermes A. Kontos, M.D., PhD
Chief Executive Officer
VCU Health System
DATE:
________________________

NON-EMPLOYEE INFORMATION
PLEASE PRINT
MCVH Human Resources Email: tstanley@mcvh-vcu.edu (Lotus Notes) or Fax: 628-0014
Reason for Form Submission: ! New ! Change ! Separation ! Replacement ID required (send to VCUCard)
Instructions: For New Assignments, complete entire form.
For Changes, complete Name, SS#, Section B, and change.
For Separations, complete Name, SS#, Section B, and separation date (Section C).
For Replacements, complete Name, SS#, Section B and email to VCUCard
(VCUCard@aspen.vcu.edu) or fax (828-8855)
PRINT ALL INFORMATION
Category: ! Student ! Volunteer ! Contractor ! Licensed/certified practitioner ! Physician
! Corrections Officer ! Other(specify)______________________________________________
3.! Also employed by MCVH or MCVP (circle which)
Section A. Individual Data.
Name (print)_____________________________________________________ SSN ________________________
Last First Middle initial
Address: _____________________________________________________________________________________
Street, PO Box or Apt. Number
City State ZIP
Home phone: ______________________ (1) Job Title/Role __________________________________
(Job titles will be changed to coincide with staff titles as needed)
Work phone _______________________ (2) Job Title/Role:__________________________________
Identification Validation:
Document Presented: Passport ___ Driver’s License _____ State/Federal Picture ID ______
Document Number: ____________________________________ State from which issued _______________
Emergency Contact(optional) ________________________________
Name
(if applicable)
_____________________
Phone
If contract employee, Employer’s Name: _____________________________________ Phone:
_________________
If student, School or Affiliation name: ______________________________________________
School Contact Name:_____________________________ Phone Number: _________________________
Will individual need supervisory access to TRS: Yes _____ No _____
Section B. Sponsoring Department Data
Sponsoring Department __________________________________ Account Code _________ MAS Code _______
(Sponsoring Departments may be charged for contractor IDs)
Authorizing Agent Name _________________________________________ Phone ________________________
Email Address _____________________________________________ Fax _______________________________
Section C. Assignment Dates
Date Assignment begins ____________________ Access Expiration Date ___________________
(anticipated last day of assignment or one year from start date if unknown)
Comments:

Non-Employee Data Form page 1 9/00
Section E. Manager Checklist for Students
3.Sponsoring departments complete the following checklist prior to returning to HR and prior to student receiving a
VCUCard.
3.
3.1. Does the sponsoring department have an affiliation agreement on file with Fiscal Services, Office of Contracts
and Agreements? Yes ____ No ____ Not Required per Contracts Office _____
3. If no, an affiliation agreement must be completed. Contact the Office of Contracts and Agreements, 828-2650
for assistance.
2. Has the sponsoring department agreed to a clinical affiliation scope of learning? Yes ____ No _____
If no, a scope of learning identifying what educational objectives and level of practice the sponsoring
department has agreed to provide for the student groups should be developed.
3. Has the sponsoring department verified with the learning institution that the student is actively enrolled in the
specified program? Yes ____ No ____
4. Has the sponsoring department verified the Identity of the student using an acceptable picture ID document?
Yes ____ No ____
5. Has the sponsoring department delineated individual(s) responsible for supervision of the student?
Yes _____ No _____ Name of supervisor: _________________________
6. Has the sponsoring department scheduled an orientation for the student?
General orientation: Yes _____ No ____
Department specific orientation: Yes _____ No _____
7. Has individual signed confidentiality agreement? Yes _____ No _____
Sponsoring Departments must maintain the following records for non-employees.
Non-Employee Staff (excluding students) Personnel File Contents
-Position Description
-Competency Assessment
-Orientation Documentation
-Verification of health requirements
-Competency Assessment
-Evaluation(s)
-Verification of License, Certification, or Registration if required for position
Student Affiliation Records
-Copy of Affiliation agreement or confirmation that agreement is in Office of Contracts and Agreements
-Scope of Practice/Learning
-Orientation Documentation (signed rosters)
-Copy of NEI form (per student or student group)
-Signed Confidentiality Agreements (per student)

Non-Employee Data Form page 2 9/00
Instructions for Completing Non-Employee Information (NEI) Form
Introduction
NEI forms must be completed and submitted by individuals designated as authorizing agents by their department
manager. For large groups, a spreadsheet containing the required fields may be submitted in lieu of individual
forms. NEI forms may be downloaded from the MCV BAS1 server shared drive in the HRForms folder.
General Information:
HR Fax number: 628-0014 VCUCard Fax number: 828-8855
HR Email Address: tstanley@mcvh-vcu.edu
VCUCard email address: VCUCard@aspen.vcu.edu
The NEI form is a two-page form. The second page is used as a checklist to indicate that all aspects of a student
affiliation have been completed prior to an ID being issued. Forms will be sent back to departments submitting
student data that have not completed this section (thus preventing the student ID from being issued.)
Departments should keep a copy of the NEI form on file in their area and submit the original to MCVH HR.
Instructions for Completing:
Reason for Submission: Indicate if the form is being submitted because this is a new non-employee role (first role)
for the individual (New), to change information previously submitted (Change), to notify HR of separation from a
role (Separation), or to notify VCUCard that a replacement ID is required (Replacement). If the reason is
“Replacement” send to VCUCard, not HR.
Category: Check all that apply for the individual if multiple roles are being identified.
Section A. Individual Data: Complete entire section for first time submissions. Name and SS# must be completed
for changes, separations or replacements in addition to other pertinent data for intended action.
Name: Individual’s last and first name and middle initial
SSN: Individual’s social security number
Address: Individual’s home address
Home Phone, Work phone: Individual’s home and work telephone number, include area code for home number.
Job Title/Role: Identity title for role they are to perform. Job titles must match MCVH job title designations.
Example for students: Nursing Student, Medical Student, etc. Contact HR if assistance is needed in identifying title
that should be entered.
Identification Verification:
Document Present: Check which form of documentation was used to identify individual.
Document Number: Usually social security number but may differ for passports or states other than Virginia.
State: The state should be completed if a driver’s license or state issued ID is used.
Emergency Contact, Phone: Who should be contacted in case of injury or medical emergency? (optional)
If contract staff, Employer’s name: Name and phone number of contractor/agency who actually pays individual.
If student, School or Affiliation: Name of the school or training facility/organization with whom this student is
affiliated. List your contact at that school and their phone number.
Will individual need supervisory access to TRS? Indicate if this person’s role will involve timekeeping
requirements and therefore access to TRS. HR will notify Payroll if checked yes.
Section B. Sponsoring Department Data
Sponsoring Department: Department name authorizing individual to be here. Example: hired the company to
provide staff services or agreed to provide educational experience to student.
Account Code: VCUCard charges departments to issue IDs to contractors. Enter the code you would use to pay this
charge.
MAS Code: MAS code of sponsoring department

Authorizing Agent: Name of individual who completed form. Individual must be authorized by department
manager. Authorizing Agent’s phone number, fax number and email address: as stated
NEI Form Instructions page 1 9/00
Section C. Assignment Dates
Date Assignment Begins. Date department first expects individual to be onsite
Access Expiration Date: Required field. Date department expects individual to leave. If no date is entered, HR will
assign expiration as one year from date assignment begins.
Comments: As needed
Section E. Must be completed for all student roles.
1. Does the sponsoring department have an affiliation agreement on file with Fiscal Services? If no, an affiliation
agreement must exist prior to students being brought on site. The Office of Contracts and Agreements should
be contacted to determine if an agreement exists or if one is required for a particular situation.
2. Has the sponsoring department agreed to a clinical affiliation scope of learning? A guide has been established to
assist departments in identifying what should be included in a scope of learning. See policy 2135, Student
Learning Experience.
3. Has the sponsoring department verified with the learning institution that the student is actively enrolled in the
specified program? Example: Confirm that a student who says he is a nursing student at VCU is actually
enrolled in the nursing program at VCU and in which year.
4. Has the sponsoring department verified the identity of the student? Must use picture ID as noted previously
5. Has sponsoring department delineated individual responsible for supervision of student? This would be an
MCVH&P staff member, not the school facility member.
6. Has the sponsoring department scheduled an orientation for the student? Students do not have to attend general
staff orientation. However, orientation to policies such as safety, infection control, confidentiality, guest
relations, etc. must be provided as well as unit specific orientation. Orientation must be documented and
maintained by the sponsoring department.
7. Has the individual signed a confidentiality agreement? All staff and students must sign a confidentiality
agreement prior to having access to any patient or enterprise confidential information. Signed agreements must
be maintained by sponsoring departments.
At the Bottom of page two is a list of documents departments should maintain on contract staff and students.

NEI Form Instructions page 2 9/00