OSR EPIC Access Request Form

Office of Student Research Bressler, Suite M-019 655 West Baltimore Street Baltimore, MD 21201 410 706 3026 StudentResearch@som.umaryland.edu http://medschool.umaryland.edu/osr

EPIC Access Request Form

Office of Student Research

Completion of this form is required before receiving EPIC access.

Student's Information

You will be required to complete Epic training. The information you provide below will only be used to set up your Epic training account and to complete your Epic Access request form through the UMMS portal.

First Name *

Last Name *

Class Year *

Ex. 2023

Dual Degree *

Email (please use your school email) *

example@som.umaryland.edu

Phone Number (please use the best number to reach you) *

(XXX) XXX - XXXX

Last 4 of SSN. *

DOB (mm/dd) *

Please only include Month and Day.

Mentor's Information

This information wil be used to submit your approval request to your UMB or UMMS Faculty mentor.

Mentor's First Name *

Mentor's Last Name *

Mentor's Email (please make sure the email address you list is the best SOM or UMM email for your mentor) *

Confirmation Email example@example.com

Mentor's Department *

Please Read:

Step 1: Once you have been notified that your portfolio training account has been created, please complete the training within 15 days.

Step 2: Submit your certificate of completion to studentresearch@som.umaryland.edu.

Step 3: When your request has been submitted you will be required to complete the confidentiality agreement. You should expect an email from UMMS IST Service Desk, UMMS_IST_Service_Desk@umm.edu. (Subject: UMMS Application Access Request - Confidentiality Agreement Link - Time Sensitive)

When you receive your email, be sure to do the following:

1. Complete the Confidentiality Agreement(s)

Step 4: Once you receive your new account request information from IST Cherwell Support, ISTCherwellSupport@umm.edu. Be sure to log in within 24 hours of receiving your EPIC username and temporary password.

Step 4: For assistance with logging on to my remote, please contact the UMM Helpdesk at (410) 328-4357 or helpdesk@umm.edu.

If you have any questions, feel free to email your questions to studentresearch@som.umaryland.edu.

I read and understand the above steps. *

Yes No

Additional Comments

Thank you for taking the time to complete this form.