Form J-119 - Data Sharing Request/agreement Page 3
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8J-119 DSA (7-17) - Page 3 of 8
Agreement No.
SECTION I. (Cont.) REQUEST (Completed by Requesting Entity)
Use attachment if necessary
2. CITE LAW, REGULATION, DIRECTIVE OR OTHER BASIS FOR THIS REQUEST
3. WILL OTHER ENTITIES INTERFACE/WORK WITH YOUR ORGANIZATION?
Yes
No
If Yes, identify entity and reason(s):
4. WILL INFORMATION BE DISCLOSED/SHARED WITH ANOTHER ENTITY/ORGANIZATION?
Yes
No
If Yes, identify the entity/organization and reason(s) for disclosure:
5. WILL DES DATA BE STORED IN ANY FORM OF (DATABASES, FILES, TAPES, PAPER COPYS, ETC.)? WILL DATA BELONGING TO DES BE
STORED IN A SECURE SPECIFIED ON-SITE LOCATION?
Yes
No
If Yes, identify where, what type of data and how the data is to be stored, and for how long?
6. WHAT ARE THE SAFEGUARDS IN PLACE TO GUARD AGAINST UNAUTHORIZED ACCESS/DISCLOSURE OF THE INFORMATION; ACCESS
CONTROL PARAMETERS, ROLE BASED ACCESS, ETC.
Computers and stored in secure
Encryption
Secure Physical Location
Locked File Cabinet
8 Characters or more Password Location
Role based Access Permissions/Need to know
6a.
IF AN INFORMATION BREACH SHOULD OCCUR, WHAT ARE YOUR PROCESSES AND PROCEDURES TO ADDRESS THIS?
(SEE SECTION 2, #6)
7. HOW WILL THE INFORMATION BE PRESENTED FOR USE? WILL THE INFORMATION BE POSTED, DIGITALLY COPIED, APPLICATION, ETC?
8. HOW WILL THIS INFORMATION BE DISPOSED OF WHEN NO LONGER NEEDED? SEE RETENTION POLICY.
Print Name and Title of Authorized Contact:
Phone:
Fax:
E-mail:
Date:
Mailing Address/Mail Drop:
City:
State:
ZIP Code:
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