MOU ISA Review Form-.pdf

Memorandum of Understanding/Interconnection Security Agreement Review Form

Connection ID#:

MOU/ISA Document File Name:

ISSO and PO Initial Review Concurrence and Signature

As the Information System Security Officer (ISSO) for this MOU/ISA, I have determined that security requirements set forth in the applicable VA directives and handbooks covered by this agreement exist and are appropriately addressed. I concur with the security requirements outlined in this MOU/ISA.

As the Privacy Officer (PO) for this MOU/ISA, I have determined that the legal authorities for sharing the data covered by this agreement exist and are appropriately addressed and the uses and disclosures of the data covered by this agreement are in accordance with VA and VHA directives. I concur with the privacy practices outlined in this MOU/ISA.

Annual Review – For the Annual Review to be marked complete, the Date of Review, Review Comments, ISSO Signature and System Owner Signature blocks must be completed. Review Comments must be descriptive and provide details of the review.

Date of Review Review Comments ISSO Signature

System Owner Signature

ISSO Signature

System Owner Signature

Date of Review Review Comments ISSO Signature

ISSO Signature

System Owner Signature

ISSO Signature

System Owner Signature

ISSO Signature

System Owner Signature

ISSO Signature

BRD Approved form 06162020