Usaac Information System Access Request - Us Army Jrotc
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2USAAC INFORMATION SYSTEM ACCESS REQUEST
(For use of this form see USAAC Reg 380-XX to be published)
PRIVACY ACT STATEMENT
AUTHORITY: 5 USC 552a(e)(3)(A) and 40 USC 1441.
PRINCIPAL PURPOSE: Used to identify, verify, and authorize automated information systems (AIS) users and assign user identification codes required
to access USAAC host systems.
ROUTINE USES: To assign user ID code(s) and add user ID for access to USAAC host system(s).
DISCLOSURE: Voluntary; however, failure to furnish requested information will result in denial of user ID issuance and access to the USAAC host
system.
TYPE OF REQUEST
INITIAL
MODIFICATION
DELETION
PART I (To be completed by User)
1. NAME
a. Last
b. First
c. Middle
d. Generation
2. SOCIAL SECURITY NUMBER
3. GRADE/RANK
4. PHONE (DSN or Comm)
5. OFFICE SYMBOL/DEPARTMENT
6. RSID
N/A
N/A
7. JOB TITLE/FUNCTION
8. AKO E-MAIL ADDRESS
9. COMMAND OR ORGANIZATION
10. BRIGADE OR DIRECTORATE
11. BATTALION OR DIVISION
12. COMPANY OR BRANCH
N/A
14. PLACE OF BIRTH
13. DATE OF BIRTH
15. US CITIZEN
(dd/mm/yyyy)
a. CITY
b. COUNTY
c. STATE
d. COUNTRY
Yes
No
I have read and understand the USAAC Information Systems Security Briefing for Users, Supervisors, and Managers of Automated Information
Systems.
16. USER SIGNATURE
17. DATE
(dd/mm/yyyy)
PART II (To be completed by User's Supervisor)
18a. ACCESS REQUIRED
18b. IF ARISS ACCESS REQUIRED, INCLUDE APPLICANT TYPE, MODULE,
USAAC-NET
E-MAIL
AND MODULE ROLE AS LISTED IN BIGSUR.
.MIL PORTAL
PKI
ARISS
N/A
APPLICANT TYPE:
COGNOS
CCIMS
TSACS
N/A
FAZR
ROLE:
COML ISP
HRAP
UAN w/INTERNET
N/A
LEADS
ROLE:
JROTC Template
OTHER:
N/A
MPA
ROLE:
OTHER:
N/A
PER
ROLE:
19. ACCESS TO CLASSIFIED REQUIRED?
20. TYPE OF USER
FUNCTIONAL
APPLICATION DEVELOPER
IAM/IASO
OTHER:
NO
YES
SYSTEM ADMIN
MIRROR:
21. JUSTIFICATION FOR ACCESS
22. JOB TDA PARA AND LINE NO.
N/A
JROTC instructors require access to DoD and DA applications
VERIFICATION OF NEED TO KNOW
I certify that this user requires access as requested in the performance of his or her job function.
23a. SUPERVISOR NAME (Last, First, MI)
23b. PHONE NUMBER
23c. SIGNATURE OF SUPERVISOR
23d. DATE
(dd/mm/yyyy)
PART III (To be completed by User's Security Manager)
24. CLEARANCE LEVEL
25. TYPE OF INVESTIGATION
26. DATE OF INVESTIGATION
27. CHECK BOX IF NO RECORD OF
INVESTIGATION ON FILE
(dd/mm/yyyy)
28a. SECURITY MANAGER'S NAME (Last, First, MI)
28b. PHONE NUMBER
28c. SECURITY MANAGER'S SIGNATURE
28d. DATE
(dd/mm/yyyy)
USAAC Form 101, Rev 1 Feb 10
V3.10
PREVIOUS EDITIONS ARE OBSOLETE
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