Form Gen 1321a - Data Security Access Request

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Health and Human Services Data Center (HHSDC)
Stephen P. Teale Data Center (Teale)
DATA SECURITY ACCESS REQUEST
Process No.: ______________________________________
Requested Completion Date: _________________________
(FOR CDSS RACF ADMINISTRATOR USE ONLY)
Attached is a list of additional items due to limited space on this form.
Data Center (Check the appropriate box or boxes):
HHSDC
Teale
User Category:
Natural User
Programmer
(Check the appropriate box or boxes)
LIS
CPS
NPM
MAI
DPM
PQC
SHS
FFM
QNA
WIS
IFD
SHS
Other (specify)
JRS
TNF
LIS
WIS
MAI
Other (specify)
User Name: _____________________________________________________
Existing Userid: BP __ __ __ __ __
(LEGAL LAST NAME, FIRST NAME, MIDDLE INITIAL)
Userid Section (Check the appropriate box or boxes and supply the necessary data):
A. Create new Userid (Assigned by RACF Administrator) BP __ __ __ __ __
B. Userid will be used ONLY for FTP or Connect Direct (data transmission)
C.
i
Delete Userid BP __ __ __ __ __
D. Activate Userid BP __ __ __ __ __ on date __________________________
E. Suspend Userid BP __ __ __ __ __ on date __________________________
F. Reset Password for Userid BP __ __ __ __ __
Data Set Section (Check the appropriate box and supply the necessary data)
ii
A.
New Data Set(s) to be accessed/secured
iii
Access Authority
Data Set Name(s)
Read/Copy
Update/Change
Create/Delete
B.
iv
Delete Data Set(s) security protection
Data Set Name(s)
GEN 1321A (11/03)
PAGE 1 OF 2

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