Vendor Training Request Form

This form must be completed by the vendor who is requesting access to an Ascension site of care. A form will need to be filled out for EACH vendor representative wishing to come onsite. Training may only be requested for one site with a specified time-frame. Any falsification of the information on this Training Request Form will be treated as a policy violation. Please ensure the information is for yourself only and any requesting clinician contact is true and accurate. Incomplete forms will not be reviewed. **Please do not submit any PHI through this form or related attachments.** Smartsheet preferred browsers: Chrome and Microsoft Edge. If having trouble with submission try filling out the form in incognito mode.

Symplr Light Status*

If you are unaware of your Symplr status, please login to Symplr.com. Falsification of this form or a "Red Symplr Status" will result in automatic denial.

Red

Yellow

Green

Please Upload Clinician Email Request: Please Utilize PDF when possible*

1. Upload email correspondence from clinician/physician/Ascension or The Resource Group requester indicating a request for training and the facility where the training is to occur. 2. For Medication training requests please also include all training materials to be used during training.

Drag and drop files here or

Requester Symplyr Status*

Vendor must be fully credentialed in Symplr in order to enter any Ascension facility. Please select your current Symplr access level:

Select

Requester Email*

Please Enter your Email here

Requester Phone Number*

Use the following format: xxx-xxx-xxxx

Phone

Manufacturer Name*

Company Name*

Is this for Pyxis Equipment*

Select

Pyxis Customer Order #*

Are you requesting training for a product or a medication?*

Select

Medication Name*

If this is a medication, you must provide the full name of the medication.

Product Category*

Select

Product Description*

Select or enter value

Describe your product

If your product does not fit within our current categories - please briefly describe in your own words below.

Catalog ID # for Equip or NDC # for Medication*

This is the number that identifies one product from another (eg. VIN in a car or UPC on a product at a store). Please separate numbers with a comma. Must be completed. Using N/A will result in automatic denial.

Product Contract Status*

Select

Provide requesting Clinician's Name*

Email proof of request should be attached at the top of this form.

Requesting Clinician Title*

Requesting Clinician Department*

Clinician Email*

Must include correct clinician email or request will be denied.

Clinician Phone Number*

Must include correct clinician phone number.

Training Facility Requested*

Please select facility that training will be performed at.

Select or enter value

Are you requesting to provide additional/supplementary training on product/medication already being used at the selected facility?*

Select

Type of Facility*

Select

City*

State*

Select

Training Audience*

A description of the audience receiving training: ie, ER Nurses, Cath Lab Physicians, NICU nurses, etc. Please select all that apply.

Select

Description of Training*

Does this training provide Continuing Education?*

Select

Suggested Date Range (Start)*

Please recommend a date range for the training to occur. Select the first date here.

Suggested Date Range (End)*

Please recommend a date range for the training to occur. Select the last date here.

Length of the Requested Training*

For scheduling purposes, please describe the length of the training.

Location of Training*

Help us spread awareness among our caregivers. Tell us the exact location the training will take place. (ie: auditorium name, room name, room number, unit name, etc)

Vendor Representative Name*

I CERTIFY THAT THIS INFORMATION IS TRUE (Please Enter Your Name Here) ***DO NOT ENTER YES*** Must be the name of the training vendor representative. Please enter vendor representative name as it appears in Symplr. If 'Yes' is entered or this is filled out by someone other than the person performing the training the form will be automatically marked incomplete and returned without further vetting.

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