Department Of Veterans Affairs Request For Government Furnished Equipment (Gfe)
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1REQUEST FOR
GOVERNMENT FURNISHED EQUIPMENT (GFE)
USER INFORMATION
1. NAME (Last, First, MI)
2. TELEPHONE NUMBER
3. LEADERSHIP ROLE
4. JOB TITLE
5. OFFICE/SECTION
6. REQUEST FOR:
Printer
Thumb Drive
Desktop PC
Laptop
Numeric Pager
Alpha Pager
Cell Phone
Air Card
Blackberry
Other:
Note: Provide a brief description of required IT equipment related to the position, complexity, and level
7. JUSTIFICATION
of communication required in position
USER RESPONSIBILITIES
I understand this equipment is provided for official government use only
I understand the transit of VA information off-site is strictly prohibited unless accompanied by express written authorization
I accept responsibility for the equipment identified above, issued to me by the Department of Veterans Affairs, STVHCS
I understand that if this equipment is lost or stolen, it will be reported to the ISO and the IT Help Desk within one hour
I will care for and protect equipment from loss or damage and will notify IT staff of any damage or operational failures incurred
I understand that I will be billed for the replacement cost for any damages or loss occurring as a result of negligence
I understand that if I am re-assigned from my service or position, I will promptly return this GFE to the IT Help Desk
I will agree to and follow VA Handbook 6500, Appendix G, Department of Veterans Affairs (VA) National Rules of Behavior
I will agree to protect all patient health information & ensure confidentiality
WIRELESS DEVICES AND MOTOR VEHICLES
Use of wireless equipment while operating a vehicle is strongly discouraged and may present a hazard to the driver, other employees
and the general public. Employees should plan the placement of calls, text messaging or emails either prior to traveling or while on
rest breaks. Sending or responding to text messages or email while driving is strictly prohibited. Employees must not use wireless
equipment while driving if Federal, State or local law, regulation or ordinance prohibits such use. Should an employee need to place
a business call or respond to an email or text message while driving, he/she should locate a lawfully designated area to
safely park and use your wireless equipment. For additional guidance with regard to conditions of use and security, see
VA Directive 6001 (Limited Personal Use of Government Office Equipment Including Information Technology)
and STVHCS Policy Memorandum 003-11-04 (Automated Information Systems (AIS) Security Policy.)
DATE
SIGNATURE OF REQUESTER/USER
I hereby endorse this request based on the justification stated above
DATE
SIGNATURE OF SERVICE CHIEF/ADMINISTRATIVE OFFICER
THIS REQUEST IS
Approved
Explore Alternative Options
Disapproved
DATE
SIGNATURE OF ASSISTANT DIRECTOR
(FCIO SIGNATURE FOR TENANT EMPLOYEES)
OI&T FORM
10-0433
FEB 2012
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