36C24918R0178-006.docx

ATTACHMENT 4: VISN 9 ACCESS REQUEST

VISN 9 ACCESS REQUEST

REQUEST ACCESS TO VISN 9 STATION (S): (TVHS, Lexington, Huntington, etc.):

* Requests for system access by remote users shall be requested in writing to the IRM Chief or designee(s). The request shall state the individual's name, service, telephone number, mail routing symbol, and purpose for access and shall have the concurrence of a higher-level official within the requestor's facility.

Duty Title:

Routing:

Network Name: VHALOU_____________________

Supervisor's email: _________________________________________ Supervisor's Phone: _________________________

CURRENT DUTY STATION/AGENCY:

Cyber Security Awareness training completion date: HIPAA Privacy course completion date:

Non-VA Employee: |_| Security clearance or SAC (Fingerprint check) initiated or completed on:

Volunteer |_| Student |_| WOC |_| Medical Resident |_| Contractor |_| Projected termination date:

Note: Access requests for VA systems will not be processed prior to confirmation that the security clearance and/or SAC (Fingerprint check) has been initiated or completed.

Network account: |_| Outlook/Exchange account: |_|

VISTA: |_| VISTA TEST: |_|

FORUM: |_| _______________: |_|

CPRS: |_| National Provider ID: Degree:

Co-signature required: |_| User Class: Person Class Taxonomy Code V: Person class effective date:

One-VA VPN Access: |_| (Provide justification below) Remote access device: |_| VA Issued PC/Laptop |_| Personal PC/Laptop Personal PC Firewall software _____________ (Type, version) Personal PC Virus software ____________ (Type, version) Personal PC Hard Drive Encryption software ______________________ (Type, version) One-VA VPN Justification:

Secondary Menu Option(s):

Additional menu options that require ADPAC initialed approval for their package.

Security Key(s): (ADPAC initial approval for their Security Key(s):

CIO

Date

Service Chief

** Service Chief/Line Manager Certification: I have Ensured that all VA procedural and regulatory Requirements have been accomplished and the Applicant is authorized to access VA systems.

Appropriate Quad Member

ISO

Martin J. Traxler, Medical Center Director

D