Cdss System And Application Access Form printable pdf download

Cdss System And Application Access Form

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CDSS SYSTEM AND APPLICATION ACCESS FORM

The CDSS System and Application Access Form (GEN 1321) is used to authorize, change and terminate access to all

systems and applications containing CDSS data. The information on this form must be kept current. It must be signed by the

Supervisor and the appropriate System Administrator(s). It must also be signed by the user before he/she obtains access.

(Note: the user’s signature is not required to initiate the request.) When an employee separates from the Department,

requests to terminate access must be submitted to the appropriate System Administrator(s) as soon as possible and no later

than one business day after the employee’s separation date. All completed forms are to be ﬁled locally.

Step 1 REQUESTING ORGANIZATION:

1. Complete Sections 1 through 8 (complete only system and application names in Section 3).

2. Forward the CDSS System and Application Access Form (GEN 1321) to the Information Security Officer

(ISO) for signature, only if necessary (See Section 9). The ISO will return the form to the requesting

organization.

3. Forward the completed form to the appropriate System Administrator(s). If access is requested for more than

one system or application, concurrently route copies of the form to all appropriate System Administrators.

4. Upon completion by the System Administrator(s), forward all completed forms to the user for signature.

Step 2 SYSTEM ADMINISTRATORS:

1. Complete Sections 3 and 10.

2. Return the completed form to the Supervisor.

Step 3 USERS:

1. Complete Section 11.

2. Return the completed form to the Supervisor.

SECTION 1 - Access Request Type (to be completed by the requesting organization)

Check ( ) Only One / Complete Unit Data:

Information Systems Division Modiﬁcations:

(Not Applicable to RACF)

New Access

(All Sections)

Change Access

(All Sections)

Terminate Access

(Sections 1, 2, 4, 7, 8, 10)

For Changes to Access:

Other

Indicate Name or Location of Server/System

From __________________ to ___________________

Current Bureau/Unit/Index ____________________________

For New Server Access:

Receiving Bureau/Unit/Index __________________________

Indicate Name or Location of

System/Server ________________________________

Effective Date ______________________________________

SECTION 2 - User Information (to be completed by the requesting organization)

LAST

FIRST

USER NAME

Check if name change

LAST

FIRST

FORMER NAME

[Complete if box above is checked]

COMPANY (FOR NON EMPLOYEES)

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

FAX NUMBER

E-MAIL ADDRESS

GEN 1321 (3/00)

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Cdss System And Application Access Form

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