Associate Identity Request Form (A.I.R.)

Demographic Information

The Associate Identity Request Form (A.I.R. Form) is used to validate information about a user from a Kaleida Health Partner. When the A.I.R. form is received, CyberSecurity will submit the request to the Partners Organization Approver for approval and to the Kaleida Health Manager for approval. Upon approval, the user will receive a Kaleida Health "Associate" number. The “Associate” number will entitle the user to certain resources within Kaleida Health.

If you need assistance, please contact the Kaleida Health the Service Desk at (716) 859-7777.

Organization Information

Organization

Please select a valid organization.

Organization Name

Remaining Characters: 25

Click on an organization below if this matches your organization name:

What is your job title?

Please input a valid job title.

Choose an Organization Approver

Your Organization Approver is a person who can validate that you work for the organization that you are applying for access on behalf of.

Please select a valid organization and approver.

Company Approver First Name

Approver already Exists in the list above, please choose this approver or provide a valid name.

Company Approver Last Name

Approver Already Exists in the list above, please choose this approver or provide a valid name.

Company Approver Phone Number

Please provide a valid phone number ###-###-####.

Company Approver Email

Please provide a valid email.

To help speed up the processing of your AIR Request, please provide the following information if possible:

Company Human Resources Email Contact

Please provide a valid email.

Company Cybersecurity Email Contact

Please provide a valid email.

Company Legal/Compliance Email Contact

Please provide a valid email.

Company Office Manager Email Contact

Please provide a valid email.

Company Office Manager Phone Number

Please provide a valid phone number.

Please call the Service Desk at (716) 859-7777 if your Organization Approver is not listed.

What does Approval Pending mean?

If you see an "approval pending" status, this means that this is a new company or approver that is currently being validated by Kaleida Health. Due to the time that it takes to validate necessary information, requests containing items with this status may take longer to approve.

Additional Details

Will you be working in a Kaleida Health Facility?

Yes

Please select a value.

Location

Please select a valid location.

What Kaleida Department are you working with?

Please select a valid department.

What is your job role?

Please select a valid job.

What do you need access to?

InfoClique

Please select a valid access type.

Access Required Date

Please select a valid date.

What is your End Date?

Please select a valid date.

Additional Notes

Demographic Information

Demographic Information

Organization Information

Your Organization Approver is a person who can validate that you work for the organization that you are applying for access on behalf of.

If you see an "approval pending" status, this means that this is a new company or approver that is currently being validated by Kaleida Health. Due to the time that it takes to validate necessary information, requests containing items with this status may take longer to approve.

Additional Details

Submitting Request