Non-Employee Personnel Action Request


The form applies to all contract workers and other non-employee individuals at a UMMC facility.
For additional information, please visit http://www.umc.edu/NEPAR.
* denotes a required field.

This form MUST be completed by the non-employee named on the form.

The UMMC employee who has agreed to serve as a sponsor will receive this information once you have submitted the form. The UMMC employee who has agreed to serve as a sponsor will utilize this information to submit a UMMC non-employee request and will provide you with further instructions. You are not authorized to engage with the institution until notified by your sponsor that the request has been approved and that all UMMC onboarding requirements and procedures are complete (i.e., Student Employee Health review, compliance training, information security agreement, criminal history clearance, badging, and educational observer forms if applicable).

Non-Employee Information

*First Name:
Middle Name:
*Last Name:
Preferred First Name:
Other Names Used:
*Driver's License/State ID Number:
*Driver's License State
(select other for non-US residents):
*Passport Number (if no Driver's License/State ID):
*Date of Birth
(MM/DD/YYYY):
*Primary Phone:
Secondary Phone:
Cell Phone for ALERT U Emergency Notifications
(On Campus Only):
*Address:
*City:
*State
(select other for non-US residents):
*Zip:
*Email Address:
*Are you currently on visa or in need of visa sponsorship?
*Are you a former UMMC employee or student?
*Are you a current UMMC employee or student?
If Yes, Employee or Student ID Number:
*Age Range:


*Is this for educational credit at a school in which you are
currently enrolled?
*UMMC Sponsor Name:
*UMMC Sponsor Email: @umc.edu
 

Additional Information

*Please review the Information Security Awareness video and UMMC Acceptable Use Policy.
*Please review the Compliance Training.
Once you have reviewed the training material and policy, you will need to complete the acknowledgment statements below.

*I acknowledge that I have viewed the Information Security Awareness video and have read, understand, and agree to abide by the security policies in the UMMC Acceptable Use Policy.

*I acknowledge that I have read, understood, and agree to abide by the Compliance Training provided.

* I acknowledge that for the duration of my engagement with the University of Mississippi Medical Center (UMMC) that I have an affirmative obligation to immediately disclose any changes to my criminal history record including charges resulting from arrests, criminal convictions of both misdemeanor and felony crimes, and addition to a sex offender registry after my date of background clearance. I attest that I have submitted any changes to my criminal history record to UMMC Human Resources using the Change of Criminal History Record Disclosure Form since the date of my last background clearance.

By submitting this form, I acknowledge that all information presented is true and accurate to the best of my knowledge. I understand that I am not authorized to engage with the institution until notified by a UMMC sponsor that the request has been approved and that all UMMC onboarding requirements and procedures are complete.