This form must be submitted through the EarthMed Support Page.

EarthMed User Registration Form

For Doctors and Nurses

Part A. To be completed by the Head of Service

1. Requested Action:

2. Service (Clinic) Name:

3. User:

Last Name First Name

4. Staff Member (including UNV)? Yes No

5. Index Number: ( Mandatory for staff members and UNVs)

6. Email Address:(Mandatory for Staff Members and UNVs. Must be an official email address.)

7. For new users only:

(Not required for UN, IAEA and UNICEF staff members.)

Date of Birth: Gender: Female Male

Duty Station:Nationality:Organization:

8. For New Users and Access Modification:

9. For New Users and Access Modification:

10. Account start date: (Mandatory for all requests)

12. Requesting Head of Service:Signature Date

Part B. To be signed by the Medical Director

13.Approved by: Dr. Jillann Farmer

Dr. Bernhard Lennartz

Dr Mike RowellSignature Date

EM.02 (2020-01)

Case Manager

If "Case Manager" is selected, Part B of the form needs to be signed by the Medical Director.

The signature of the Medical Director is required when:- requesting access for non-staff users OR- selecting "Case Manager" attribute.

Main Role

Name

11. Account expiration date: (Mandatory for non-staff and inactivation of users, optional for others.)