FACILITY ACCESS AUTHORIZATION REQUEST FORM INSTRUCTIONS
Name of the individual who requires access.
Date of the request.
Enter the PSU-ID (employees) or Driver’s License number (non-employees), as applicable.
Phone number of the Requestor.
Email of the Requestor.
Department or Company Name of the Requestor.
Please enter, or legibly PRINT, the name of the Requestor’s Immediate Supervisor / Sponsor.
Please enter, or legibly PRINT, the name of the Requestor’s Next Level Manager. (NOTE: This typically relates to OPP access requests.)
Specify the area(s) where the Requestor needs access, providing details such as Building name(s), ﬂoor(s), Room number(s) and/or other deﬁning details, as necessary.
Specify WHY the requestor requires access to said locations. Explain clearly. Attach explanatory details if needed
Indicate the duration access is required. Check “permanent” for standing employees, “temporary” for those only needing access temporarily (short periods of time). Enter both start and ending dates.
Indicate the days and times of day that access is required.
The Immediate Supervisor / Sponsor and Next Level Manager (where applicable; this typically relates to OPP access requests) must sign and date, affirming that the Requestor has been advised of their responsibilities under policy AD68 and that they have provided a copy of the policy, if requested. Likewise, the Access Coordinator must sign and date, affirming that they have reviewed the details of the access request and concur with the request for access.
The Access Coordinator will determine the type of device required to access the area(s) requested, as detailed in Procedure SY2001.
Prior to receiving the appropriate access device, the Requestor must sign and date, affirming that they have been advised of policy AD68, are aware of their responsibilities in receiving access, and in accepting keys and/or ACDs from the Access Coordinator, agree to comply in full with the terms specified on the form and all related University policies.