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Access Request Form

The Access Request Form is designed for managers or supervisors to request system access for employees, including those requiring PHI data approval. It requires employee information, the specific systems and roles requested, and an approval signature from the user's supervisor. Once completed, the form must be submitted with a help desk ticket for processing.

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92 views2 pages

Access Request Form

The Access Request Form is designed for managers or supervisors to request system access for employees, including those requiring PHI data approval. It requires employee information, the specific systems and roles requested, and an approval signature from the user's supervisor. Once completed, the form must be submitted with a help desk ticket for processing.

Uploaded by

it
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Access Request Form

Instructions:

1. Please indicate which system(s) access is being requested for.


2. A Manager or Supervisor must complete this form to request access for their employee.
3. For those systems containing PHI data, this request form must be provided to your Department’s
Academic Administrator or Department Head/Director for secondary approval.
4. Once the necessary approval is obtained, the requestor may submit a help desk ticket attaching both
the request form and written secondary approval (where applicable).

Part 1: EMPLOYEE INFORMATION


New Request Change Request Click here to enter a date.
Date

Click here to enter text. Click here to enter text.


Employee Name (Last, first, middle initial) Network ID
Click here to enter text.
Employee Title

Click here to enter text. Click here to enter text.


Primary phone number Email address

Part 2: SYSTEM ACCESS

Please indicate for which applications, shares and environments you are requesting access. If role-
based access exists, please identify the role requested.

Application Role (if applicable)


Dropbox
SAS (Statistical Analysis System)
RD Web (Remote Desktop Web Access)
Other
Click here to enter text.

Share Drive Access Network Path (e.g.\\servername\sharename$\foldername)


Enter Share Name Click here to enter text.
Enter Share Name Click here to enter text.
Enter Share Name Click here to enter text.
Other
Enter Share Name
Access Request Form

Environment Role/Group (if applicable)


rSTAT
Other
Click here to enter text.

1. Is the identified access and level of access required for this employee to carry out his or her job
duties, functions, and responsibilities? Yes No
2. Have you made reasonable efforts to limit access to what is needed? Yes No
3. Reason for access request or change: Click here to enter text.
4. Comments (if any): Click here to enter text.

Part 3: APPROVAL
User’s Supervisor: By signing this form, I approve the access request change and certify that this user
requires access to be added or changed (as indicated in this form) to perform his/her job duties.

Electronic Signature: * Date: Click here to enter text.


First and Last Name

*I understand that checking this box constitutes a legal signature.

Please attach this form to the Help Desk ticket.

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