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Access Request Form

1. This access request form outlines the process for requesting access to systems and applications containing PHI data. 2. The form requires the employee and manager information, requested systems and roles, supervisor approval, and instructions to submit a help desk ticket for processing. 3. Requests for access to systems containing PHI data must also obtain secondary approval from the academic administrator or department head.

Uploaded by

it mumuso
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© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
294 views

Access Request Form

1. This access request form outlines the process for requesting access to systems and applications containing PHI data. 2. The form requires the employee and manager information, requested systems and roles, supervisor approval, and instructions to submit a help desk ticket for processing. 3. Requests for access to systems containing PHI data must also obtain secondary approval from the academic administrator or department head.

Uploaded by

it mumuso
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Access Request Form

Instructions:

1. Please indicate which system(s) access is being requested for.


2. A Manager or Supervisor must complete this form to request access for their employee.
3. For those systems containing PHI data, this request form must be provided to your Department’s
Academic Administrator or Department Head/Director for secondary approval.
4. Once the necessary approval is obtained, the requestor may submit a help desk ticket attaching both
the request form and written secondary approval (where applicable).

Part 1: EMPLOYEE INFORMATION


☐ New Request ☐ Change Request Click here to enter a date.
Date
Click here to enter text. Click here to enter text.
Employee Name (Last, first, middle initial) Network ID
Click here to enter text.
Employee Title

Click here to enter text. Click here to enter text.


Primary phone number Email address

Part 2: SYSTEM ACCESS

Please indicate for which applications, shares and environments you are requesting access. If role-
based access exists, please identify the role requested.

Application Role (if applicable)


☐ Dropbox
☐ SAS (Statistical Analysis System)
☐ RD Web (Remote Desktop Web Access)
☐ Other
Click here to enter text.

Share Drive Access Network Path (e.g.\\servername\sharename$\foldername)


☐ Enter Share Name Click here to enter text.
☐ Enter Share Name Click here to enter text.
☐ Enter Share Name Click here to enter text.
☐ Other
Enter Share Name
Access Request Form

Environment Role/Group (if applicable)


☐ rSTAT
☐ Other
Click here to enter text.

1. Is the identified access and level of access required for this employee to carry out his or her job
duties, functions, and responsibilities?  ☐Yes ☐ No
2. Have you made reasonable efforts to limit access to what is needed?  ☐Yes ☐ No
3. Reason for access request or change: Click here to enter text.
4. Comments (if any): Click here to enter text.

Part 3: APPROVAL
User’s Supervisor: By signing this form, I approve the access request change and certify that this user
requires access to be added or changed (as indicated in this form) to perform his/her job duties.

Electronic Signature: * Date: Click here to enter text.


First and Last Name

 *I understand that checking this box constitutes a legal signature.

Please attach this form to the Help Desk ticket.

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