Submit a request – Department of Medicine IT Helpdesk

Please choose your issue below

Your email address

Subject(optional)

Provide a summary of your request

Division, Department, Center or Institute

NOTE: Please select appropriate Division - NOT just Department of Medicine (this is for Education, Communications, ORS, Finance, or Operations)

Brainmap Group Assignment(optional)

Select the appropriate Brainmap group assignment

Type of System Access Request

Select the type of access

Relationship to person requesting access for(optional)

Relationship to person requesting access for

DOM Account Expiration Date(optional)

Students and Honorary Appointments must have an expiration date for the DOM Login to be re-activated.

New Account First Name

New Account Middle Initial(optional)

If the person has no middle initial, enter NMI (no middle initial).

New Account Last Name

NetID

Enter Campus NetID of your New Employee. Not sure what a NetID is? More information on campus NetIDs: https://kb.wisc.edu/page.php?id=4966

New Account Start Date

Using DOM Computer

Did the new user complete HIPAA training?

HIPAA Training is required by all members of the UW HCC prior to accessing PHI and annually thereafter, and also annually by all members of the School of Medicine and Public Health. https://compliance.wisc.edu/hipaa/training/ NOTE: Even if HIPAA training has not been completed yet - please submit login request form (account can be created and ready) then let us know when HIPAA has been completed.

Building(optional)

Job Classification

System Access(optional)

Select the system(s) that the person will need access to

DOM File Share

File shares allow you to share data with groups of users. The data custodian authorizes who has access to specific files and folders.

Other System Name(optional)

Provide the system name

Comments(optional)

Provide any other comments you may have here.

Attachments(optional)

Add file or drop files here