Pyxis Access Request Form

UConn Health Create/Modify/Revoke User Account request Form for Pyxis Pharmacy System
If you have questions regarding this form, contact the Director of Pharmacy
Instructions: Department Manager or authorized designee is to complete, sign and forward the original
UConn Health Create/Modify/Revoke User Account request Form for Pyxis Pharmacy System to the Pyxis
System Administrator, Pharmacy, Mail code 2205. To expedite, forms may be faxed to ext. 1231.
Requestor Information (person filling out this form and submitting a user account request)
Requestor’s Name (Print):
Date:
Requestor’s Department:
Requestor’s Phone:
Authorized Signature:
User Information (actual person to be granted system access privileges)
User’s Last Name, First Name, M (Print)
User’s Job Title (Required)
User’s Department
Password Privileges (Check one)
Department Privileges: (Check all that apply)
AACU
ANES
CANTON-UC
CATH LAB
CS2
DERM
DERM-CANTN
EMER
FSC
H3
ICU
INFCENTER
Disable/Delete User Account:
L&D
MED3
MED4
MS5
NEO
NEWB
OB
ONC6
OR-CORE
OUTPT
PACU
PSY1
RADIO
RADONC
SDS
STORRS
SUR7
WORKRM
Standard Nurse
Standard + Temporary Password Issuance
Other (please specify)
Enter Usernames to be Disabled/Deleted:
(Sign above. Authorized Signature is Required)
_
Please keep a copy of this form for your records
I understand that my USER ID and PASSWORD constitute my unique electronic signature in the Pyxis system.
Willful abuse or inappropriate use of my User ID or Password (i.e., sharing of my ID or Password or using another
Employee’s ID or password is expressly prohibited and may result in termination. The USER ID will be used to
track all of my transactions in the Pyxis system, each of which is stamped with the date/time. My electronic
signature will be maintained and archived by the Pharmacy and will be available for inspection by the Drug
Enforcement Agency (DEA) and the state division of Drug Control, as is presently done with handwritten signatures
on controlled substance records.
Employee Signature
To be completed by Pharmacy Pyxis Manager:
User’s ID
Dated Entered
Date
Initialed:
Access Controls – Department Administered Systems
6.5.a Attachment A – Create/Modify/Revoke User Account Request Form- Department Administered Systems