JagNumber/Badge Request Form

To grant access to USA Health electronic systems, including those that contain protected health information (PHI), personally identifiable information (PII) and other sensitive data, all users must be provisioned a JagNumber (J#). This form facilitates the communication of information to USA Health Human Resources (HR), who assign the J# from the secure Banner HR system.

This form is to be completed by an applicant for an Authorized User photo ID Card for USA Health. This information will be used to obtain a J Number in the USA Banner System for identification of the Authorized User while on USA Health premises. Please present an approved Photo ID to Human Resources with form. Examples of acceptable Photo ID are on back of form.

   If you do not have a Social Security Number (e.g., not a citizen of the United States who is doing
   work for USA Health on behalf of a vendor) please provide a subsequent identifier.

     Credential Type: |      Credential #: |

Business 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   Zip: |
Home Telephone No.:	Cell Phone No.:
Daytime Contact Number: |

Outside Company/Agency:

Job Title/Position: |

   What name would you have been listed by? |

   Do you have (or think you may have had) a J#? | No Yes

I certify that the above information is true and accurate and I have received a copy of the ID Badge Policy.
| Authorized User Signature		| Date

Attach Photo ID:   X