Cdss System And Application Access Form (Page 3 of 3) in pdf

SECTION 7 - Personal Computer Administrator (PCA) Contact Information (Not Applicable for RACF):

The requesting organization must provide the name and phone number for the PCA or appropriate technical support staff.

PCA NAME (PRINT)

BUSINESS PHONE NUMBER

DATE CONTACTED

(

)

SECTION 8 - Supervisor Veriﬁcation Signature (all access action requires a supervisor signature)

NOTE: Conﬁrmations 1 - 3 and attachments are required to process a request for a new / modiﬁed access.

Only Conﬁrmation 4 is required for an access temination.

I conﬁrm that:

1. The proposed permission and/or privileges for systems and/or applications have been authorized on a “need to

know” basis (not needed for Outlook).

2. A copy of the speciﬁc permissions and/or privileges for each system and/or application is attached to this document

(not applicable for Outlook).

3. A copy of the Internet Consent Form and the CDSS E-Mail Retention Policy Acknowledgement Form will be

provided to the employee. The signed forms will be on ﬁle in the bureau/unit records within 10 working days of the

employee start date.

4. Termination action has been taken to cancel the employee’s account and, if applicable, Section 4 of this form has

been completed.

SUPERVISOR NAME (PRINT)

SUPERVISOR SIGNATURE

DATE

SECTION 9 - Information Security Ofﬁcer Signature

The CDSS Information Security Ofﬁcer signature is needed if access is requested for a user who is not a State, county or

federal employee or not working under contract (e.g., a volunteer or other such individual).

INFORMATION SECURITY OFFICER NAME (PRINT)

INFORMATION SECURITY OFFICER SIGNATURE

DATE

SECTION 10 - System Administrator Signature

After signing, each System Administrator is to send copies of the signed forms to the requesting organization.

I certify that the above access request has been completed.

I certify that the name change request has been completed.

SYSTEM ADMINISTRATOR NAME (PRINT)

SYSTEM ADMINISTRATOR SIGNATURE

DATE

SECTION 11 - User Acknowledgements and Signature

This section is to be read and completed by the user prior to receiving access to any CDSS system(s) and/or application(s).

I acknowledge that the Department has provided automation equipment for my use in performing my job duties. The

Department will grant system and/or application access to me as speciﬁed in this document. I will use the automation

equipment and system and/or application access for appropriate business purposes. I will take reasonable precautions to

protect the conﬁdential and sensitive data in these system(s) and application(s). This access will remain in force until it is

changed and documented in a subsequent change request.

All Information Security policies may be viewed on the CDSS internal web page or obtained by contacting the Information

Security and Management Systems Branch.

USER’S NAME (PRINT)

USER’S SIGNATURE

DATE

Page 3

Cdss System And Application Access Form Page 3

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