MTC Clinical Badge Request Form

Forms may be submitted for:


Clinical Groups/Instructors

Practicum/Transition/Capstone Students (Undergraduate or Entry-level MSN)

Advanced Practice Rotations (Graduate-level, NP, CNS, CRNA, PA)


Please allow at least 5 business days for your Badge Access Application to be processed. Your full social security number and Influenza/COVID vaccination dates are required for processing..


Badge Office Hours: Monday - Friday

8:30 am - 9:30 am | 2:00 pm - 3:00 pm

 

Student Information



 
 
 
 
 
 
 
 
 
Phone
 

required for badge to be processed

 
 
 

On what unit will clinical take place? - Confirm unit with Coordinator or Instructor (pick one from the list below)

 
 
 
mm/dd/yyyy
 

Vaccinations

 
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 

Badge Agreement

According to the Annotated Code of Maryland – Health – General § 19-308.4, Security ID badges are to be worn conspicuously displayed at all times, in the upper chest area, by employees and other personnel granted access, while in the Medical System Buildings. Be advised that unauthorized use of UMMC Security ID Badges may result in disciplinary action or revocation of the Badge. The Security ID Badge may not be loaned, transferred, or used by other than the individual who is pictured and named on the badge. Security ID Badges are the property of UMMC Midtown and must be surrendered to UMMC Midtown upon termination, end of contract, or when requested by UMMC Midtown Management. Personnel are responsible for lost, stolen, or damaged badges. The replacement cost is $25. Divisions of UMMS, UMC, and internal publications use the ID picture for recognition purposes, we supply only the picture and the name.