FLINDERS MEDICAL CENTRE
ID AND ACCESS REQUEST APPLICATION AND
AMENDMENTS
Please bring your completed form to the FMC Security office adjacent the Emergency Department 24
HOURS BEFORE one of the available photograph sessions on:
Tuesday and Thursday 1pm – 4pm 0r Wednesday 8am – 11am
Please ensure forms are completed clearly as delays will occur if forms are returned for clarification of
content.
All ID cards are required to display:
o Employee’s position and their function.
o Employee’s first name
• Staff are encouraged to display their full name, however staff working in a high security area may elect not
to display their surname (indicate below with name on card).
• Medical staff are required to display the title Dr on their card.
APPLICANT
Surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . First Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name on Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Additional Information eg. Title: Dr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Job Title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Department and/or Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FMC Contact Number /Pager . . . . . . . . . . . . . . . . . . . . . . . FMC. Payroll Number
Employment Status: - Ongoing Temporary Volunteer
Flinders Medical Centre Employee Flinders University Employee working at FMC
Other (e.g. Student, SA Pathology, SA Health Workforce division etc.)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If temporary at FMC, please indicate finishing date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Employee’s Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Date . . . . . . . . . . . . . . . .
• Permanent access cards will not be issued to temporary staff (less than 6 months) or to non-paid persons
such as trainees, visiting professionals and some student groups including work experience. These
persons can be issued with a standard ID card and/or a temporary access card (requiring a $10 deposit)
and can be made available on request.
• A $10 replacement fee will be charged for lost cards or where non-functional changes to job or position are
requested. Expired cards and replacement due to normal wear and tear will be replaced at no cost to
employees.
• If you are not employed directly by FMC you will need to provide identification when attending for a photo
(drivers licence or student id)
You’re FMC Divisional Manager/Departments approved authoriser will need to sign below
approving your access requirements.
Declaration
I acknowledge that as an FMC Access/ID Holder, I am responsible for:-
1. Wearing my ID card (ensuring the photo is visible) at all times when on FMC premises.
2. Reporting any lost stolen or damaged cards to my supervisor/ Manager ASAP
3. Storing cards in a secure manner when not in use
4. Reporting any suspicious persons, security issues or breaches of the FMC Security and Access Control
Policy to my Manager ASAP
5. Reporting any problems with the access control devices, duress alarms or other alarm systems in their
work area to my Manager ASAP
6. Returning my ID card to FMC Security or my Manager at the completion of my employment.
Signature of Applicant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date / /
MANAGERS APPROVAL FOR NEW OR AMENDED ID/ACCESS CARDS
I confirm that the applicant is working at FMC and requires appropriate security access to FMC services.
Please Indicate EITHER Access Card Or ID Card Only: ACCESS incl ID: ID CARD: TEMP ACCESS
For ACCESS please indicate as below and include as much detail as possible to clarify the applicant’s
level of access permissions. DO NOT request “whole of hospital access” or “whole of campus” unless
appropriate, as return for clarification will result in delays to issue of cards. Access to external doors for
entry to the building will automatically be included
STANDARD ACCESS – e.g. ICCU RN - requires full access to ICCU excluding drug cabinet
Doctor Division of Medicine - requires access to all Clinical areas.
COMPLEX ACCESS – e.g. ICCU RN - requires access to ICCU plus MET access plus drug cabinet
Nursing Director Nursing & Patient Services – requires access to all clinical
areas plus Executive suite plus Nursing & Patient Services
STANDARD ACCESS:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
COMPLEX ACCESS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Manager/Approver: - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . .
[Printed Name)
Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[Signature]
Position: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contact Number/Pager. . . . . . . . . . . . . .
OFFICE USE ONLY:
Member processing form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . .
Receipt sighted
Photo Taken . . . /. . . ./ . . . Picture No . . . . . . . . Authorisation Checked Modified Card Access ID/Plastic
Lost/Replacement Charge Card Produced . . . /. ./. . . Card No . . . . . . . . . . .
Card Collected by . . . . . . . . . . . . . . . . . . Signature . . . . . . . . . . . . . . . . . . . . . . . . Date . . . /. . . ./ . . .
