PWS Attachment 7 - DD Form2875_System Authorization Access Request.pdf
PDF 193 KB Posted
- Attached to
- Clinical Reference Laboratory Testing Services
- Solicitation number
- HT001526RE001FINAL
- Issued by
-
Defense Health Agency
About this file
DD Form 2875 is a System Authorization Access Request (SAAR) form used by the Department of Defense to record and validate access requests for DoD systems and information.
The form consists of four parts completed by different parties in sequence. Part I is completed by the requester and captures personal information including name, organization, office symbol, contact information, citizenship status, and designation (military, civilian, or contractor). The requester must certify completion of Annual Information Awareness Training and sign the form. Part II requires endorsement from the user's supervisor or government sponsor and includes justification for access, type of access requested (authorized or privileged), classification level of accessible information (unclassified or classified), access expiration date for contractors, and signatures from the supervisor, information owner/OPR, and Information Assurance Officer. Part III is completed by the security manager to validate background investigation type, clearance level, and investigation date. Part IV is completed by authorized IT staff to document specific system account details including domain, server, application, files, and datasets, with processing and revalidation dates and signatures. Original forms with signatures must be retained for one year after account termination. The form may be transmitted electronically, by fax, or by mail, and forms containing passwords must be protected as "FOR OFFICIAL USE ONLY" minimum classification. Block 27 contains optional information allowing users to specify their DHA office location from a provided list of options.
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Text version
PREVIOUS EDITION IS OBSOLETE.
DD FORM 2875, AUG 2009
SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act PRINCIPAL PURPOSE: To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to Department of Defense (DoD) systems and information. NOTE: Records may be maintained in both electronic and/or paper form ROUTINE USES: None.
DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.
TYPE OF REQUEST
INITIAL MODIFICATION DEACTIVATE USER ID
DATE (YYYYMMDD)
SYSTEM NAME (Platform or Applications) LOCATION (Physical Location of System)
PART I (To be completed by Requester)
1. NAME (Last, First, Middle Initial) 2. ORGANIZATION
3. OFFICE SYMBOL/DEPARTMENT 4. PHONE (DSN or Commercial)
5. OFFICIAL E-MAIL ADDRESS 6. JOB TITLE AND GRADE/RANK
7. OFFICIAL MAILING ADDRESS 8. CITIZENSHIP
US FN
OTHER
9. DESIGNATION OF PERSON
MILITARY CIVILIAN
CONTRACTOR
10. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS (Complete as required for user or functional level access.)
I have completed Annual Information Awareness Training. DATE (YYYYMMDD)
11. USER SIGNATURE 12. DATE (YYYYMMDD)
PART II ENDORSEMENT OF ACCESS BY INFORMATION OWNER, USER SUPERVISOR OR GOVERNMENT SPONSOR (If individual is a contractor -provide company name, contract number, and date of contract expiration in Block 16.)
13. JUSTIFICATION FOR ACCESS
14. TYPE OF ACCESS REQUESTED
AUTHORIZED PRIVILEGED
15. USER REQUIRES ACCESS TO: UNCLASSIFIED CLASSIFIED (Specify category)
OTHER
16. VERIFICATION OF NEED TO KNOW
I certify that this user requires access as requested.
16a. ACCESS EXPIRATION DATE (Contractors must specify Company Name, Contract Number, Expiration Date. Use Block 27 if needed.)
17. SUPERVISOR'S NAME (Print Name) 18. SUPERVISOR SIGNATURE 19. DATE (YYYYMMDD)
20. SUPERVISOR'S ORGANIZATION/DEPARTMENT 20a. SUPERVISOR'S EMAIL ADDRESS 20b. PHONE NUMBER
21. SIGNATURE OF INFORMATION OWNER/OPR 21a. PHONE NUMBER 21b. DATE (YYYYMMDD)
22. SIGNATURE OF IA OR APPOINTEE 23. ORGANIZATION/DEPARTMENT 24. PHONE NUMBER 25. DATE (YYYYMMDD) lboniven Highlight lboniven Highlight lboniven Highlight lboniven Highlight lboniven Highlight lboniven Highlight lboniven Highlight lboniven Highlight lboniven Highlight
DD FORM 2875, AUG 2009
26. NAME (Last, First, Middle Initial)
27. OPTIONAL INFORMATION
PART III - SECURITY MANAGER VALIDATES THE BACKGROUND INVESTIGATION OR CLEARANCE INFORMATION
28. TYPE OF INVESTIGATION 28a. DATE (YYYYMMDD)
28b. CLEARANCE LEVEL 29. VERIFIED BY (Printed Name)
30. SECURITY MANAGER
TELEPHONE NUMBER
31. SECURITY MANAGER SIGNATURE 32. DATE (YYYYMMDD)
PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION
TITLE: SYSTEM ACCOUNT CODE
DOMAIN
SERVER
APPLICATION
FILES
DATASETS
DATE PROCESSED (YYYYMMDD) PROCESSED BY (Print name and sign) DATE (YYYYMMDD)
DATE REVALIDATED (YYYYMMDD) REVALIDATED BY (Print name and sign) DATE (YYYYMMDD) lboniven Highlight lboniven Highlight
INSTRUCTIONS
The prescribing document is as issued by using DoD Component.
DD FORM 2875, AUG 2009
A. PART I: The following information is provided by the user when establishing or modifying their USER ID.
(1) Name. The last name, first name, and middle initial of the user.
(2) Organization. The user's current organization (i.e. DISA, SDI, DoD and government agency or commercial firm).
(3) Office Symbol/Department. The office symbol within the current organization (i.e. SDI).
(4) Telephone Number/DSN. The Defense Switching Network (DSN) phone number of the user. If DSN is unavailable, indicate commercial number.
(5)Official E-mail Address. The user's official e-mail address.
(6) Job Title/Grade/Rank. The civilian job title (Example: Systems Analyst, GS-14, Pay Clerk, GS-5)/military rank (COL, United States Army, CMSgt, USAF) or "CONT" if user is a contractor.
(7) Official Mailing Address. The user's official mailing address.
(8) Citizenship (US, Foreign National, or Other).
(9) Designation of Person (Military, Civilian, Contractor).
(10) IA Training and Awareness Certification Requirements. User must indicate if he/she has completed the Annual Information Awareness Training and the date.
(11) User's Signature. User must sign the DD Form 2875 with the understanding that they are responsible and accountable for their password and access to the system(s).
(12) Date. The date that the user signs the form.
B. PART II: The information below requires the endorsement from the user's Supervisor or the Government Sponsor.
(13). Justification for Access. A brief statement is required to justify establishment of an initial USER ID. Provide appropriate information if the USER ID or access to the current USER ID is modified.
(14) Type of Access Required: Place an "X" in the appropriate box.
(Authorized - Individual with normal access. Privileged - Those with privilege to amend or change system configuration, parameters, or settings.)
(15) User Requires Access To: Place an "X" in the appropriate box.
Specify category.
(16) Verification of Need to Know. To verify that the user requires access as requested.
(16a) Expiration Date for Access. The user must specify expiration date if less than 1 year.
(17) Supervisor's Name (Print Name). The supervisor or representative prints his/her name to indicate that the above information has been verified and that access is required.
(18) Supervisor's Signature. Supervisor's signature is required by the endorser or his/her representative.
(19) Date. Date supervisor signs the form.
(20) Supervisor's Organization/Department. Supervisor's organization and department.
(20a) E-mail Address. Supervisor's e-mail address.
(20b) Phone Number. Supervisor's telephone numberTex
(21) Signature of Information Owner/OPR. Signature of the functional appointee responsible for approving access to the system being requested.
(21a) Phone Number. Functional appointee telephone number.
(21b) Date. The date the functional appointee signs the DD Form 2875.
(22) Signature of Information Assurance Officer (IAO) or Appointee.
Signature of the IAO or Appointee of the office responsible for approving access to the system being requested.
(23) Organization/Department. IAO's organization and department.
(24) Phone Number. IAO's telephone number.
(25) Date. The date IAO signs the DD Form 2875.
(27) Optional Information. This item is intended to add additional information, as required.
C. PART III: Certification of Background Investigation or Clearance.
(28) Type of Investigation. The user's last type of background investigation (i.e., NAC, NACI, or SSBI).
(28a) Date of Investigation. Date of last investigation.
(28b) Clearance Level. The user's current security clearance level (Secret or Top Secret).
(29) Verified By. The Security Manager or representative prints his/her name to indicate that the above clearance and investigation information has been verified.
(30) Security Manager Telephone Number. The telephone number of the Security Manager or his/her representative.
(31) Security Manager Signature. The Security Manager or his/her representative indicates that the above clearance and investigation information has been verified.
(32) Date. The date that the form was signed by the Security Manager or his/her representative.
D. PART IV: This information is site specific and can be customized by either the DoD, functional activity, or the customer with approval of the DoD. This information will specifically identify the access required by the user.
E. DISPOSITION OF FORM:
TRANSMISSION: Form may be electronically transmitted, faxed, or mailed.
Adding a password to this form makes it a minimum of "FOR OFFICIAL USE ONLY" and must be protected as such.
FILING: Original SAAR, with original signatures in Parts I, II, and III, must be maintained on file for one year after termination of user's account. File may be maintained by the DoD or by the Customer's IAO. Recommend file be maintained by IAO adding the user to the system.
DRAFT
SAMPLE
PREVIOUS EDITION IS OBSOLETE.
DD FORM 2875, AUG 2009
Page of
INSTRUCTIONS
The prescribing document is as issued by using DoD Component.
PREVIOUS EDITION IS OBSOLETE.
DD FORM 2875, AUG 2009
Page of
SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act PRINCIPAL PURPOSE: To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to Department of Defense (DoD) systems and information. NOTE: Records may be maintained in both electronic and/or paper form ROUTINE USES: None.
DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act PRINCIPAL PURPOSE: To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to Department of Defense (DoD) systems and information. NOTE: Records may be maintained in both electronic and/or paper form ROUTINE USES: None.
DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.
TYPE OF REQUEST
PART I (To be completed by Requester)
8. CITIZENSHIP
9. DESIGNATION OF PERSON
10. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS (Complete as required for user or functional level access.)
PART II ENDORSEMENT OF ACCESS BY INFORMATION OWNER, USER SUPERVISOR OR GOVERNMENT SPONSOR (If individual is a contractor - provide company name, contract number, and date of contract expiration in Block 16.)
14. TYPE OF ACCESS REQUESTED
15. USER REQUIRES ACCESS TO:
16. VERIFICATION OF NEED TO KNOW
9.0.0.2.20120627.2.874785 DD Form 2875, "SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)" whs.mc-alex.esd.mbx.formswebmaster@mail.mil
WHS
PART III - SECURITY MANAGER VALIDATES THE BACKGROUND INVESTIGATION OR CLEARANCE INFORMATION
PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION
A. PART I: The following information is provided by the user when establishing or modifying their USER ID.
(1) Name. The last name, first name, and middle initial of the user.
(2) Organization. The user's current organization (i.e. DISA, SDI, DoD and government agency or commercial firm).
(3) Office Symbol/Department. The office symbol within the current organization (i.e. SDI).
(4) Telephone Number/DSN. The Defense Switching Network (DSN) phone number of the user. If DSN is unavailable, indicate commercial number.
(5)Official E-mail Address. The user's official e-mail address.
(6) Job Title/Grade/Rank. The civilian job title (Example: Systems Analyst, GS-14, Pay Clerk, GS-5)/military rank (COL, United States Army, CMSgt, USAF) or "CONT" if user is a contractor.
(7) Official Mailing Address. The user's official mailing address.
(8) Citizenship (US, Foreign National, or Other).
(9) Designation of Person (Military, Civilian, Contractor).
(10) IA Training and Awareness Certification Requirements. User must indicate if he/she has completed the Annual Information Awareness Training and the date.
(11) User's Signature. User must sign the DD Form 2875 with the understanding that they are responsible and accountable for their password and access to the system(s).
(12) Date. The date that the user signs the form.
B. PART II: The information below requires the endorsement from the user's Supervisor or the Government Sponsor.
(13). Justification for Access. A brief statement is required to justify establishment of an initial USER ID. Provide appropriate information if the USER ID or access to the current USER ID is modified.
(14) Type of Access Required: Place an "X" in the appropriate box.
(Authorized - Individual with normal access. Privileged - Those with privilege to amend or change system configuration, parameters, or settings.)
(15) User Requires Access To: Place an "X" in the appropriate box.
Specify category.
(16) Verification of Need to Know. To verify that the user requires access as requested.
(16a) Expiration Date for Access. The user must specify expiration date if less than 1 year.
(17) Supervisor's Name (Print Name). The supervisor or representative prints his/her name to indicate that the above information has been verified and that access is required.
(18) Supervisor's Signature. Supervisor's signature is required by the endorser or his/her representative.
(19) Date. Date supervisor signs the form.
(20) Supervisor's Organization/Department. Supervisor's organization and department.
(20a) E-mail Address. Supervisor's e-mail address.
(20b) Phone Number. Supervisor's telephone numberTex
(21) Signature of Information Owner/OPR. Signature of the functional appointee responsible for approving access to the system being requested.
(21a) Phone Number. Functional appointee telephone number.
(21b) Date. The date the functional appointee signs the DD Form 2875.
(22) Signature of Information Assurance Officer (IAO) or Appointee.
Signature of the IAO or Appointee of the office responsible for approving access to the system being requested.
(23) Organization/Department. IAO's organization and department.
(24) Phone Number. IAO's telephone number.
(25) Date. The date IAO signs the DD Form 2875.
(27) Optional Information. This item is intended to add additional information, as required.
C. PART III: Certification of Background Investigation or Clearance.
(28) Type of Investigation. The user's last type of background investigation (i.e., NAC, NACI, or SSBI).
(28a) Date of Investigation. Date of last investigation.
(28b) Clearance Level. The user's current security clearance level (Secret or Top Secret).
(29) Verified By. The Security Manager or representative prints his/her name to indicate that the above clearance and investigation information has been verified.
(30) Security Manager Telephone Number. The telephone number of the Security Manager or his/her representative.
(31) Security Manager Signature. The Security Manager or his/her representative indicates that the above clearance and investigation information has been verified.
(32) Date. The date that the form was signed by the Security Manager or his/her representative.
D. PART IV: This information is site specific and can be customized by either the DoD, functional activity, or the customer with approval of the DoD. This information will specifically identify the access required by the user.
E. DISPOSITION OF FORM:
TRANSMISSION: Form may be electronically transmitted, faxed, or mailed. Adding a password to this form makes it a minimum of "FOR OFFICIAL USE ONLY" and must be protected as such.
FILING: Original SAAR, with original signatures in Parts I, II, and III, must be maintained on file for one year after termination of user's account. File may be maintained by the DoD or by the Customer's IAO. Recommend file be maintained by IAO adding the user to the system.
| Click this button to save this form.: |
| Click this button to print this form.: |
| Click this Reset button to erase data from all fields.: |
| CurrentPage: |
| PageCount: |
| Select for "type of request - initial.": |
| Select for "type of request - modification.": |
| Select for "type of request - deactivate.": |
| Select for "type of request - user ID.": |
| Enter user ID.: |
| Enter date in format YYYYMMDD.: |
| Enter system name (Platform or Applications).: |
| Enter location (Physical Location of System).: |
| Enter name (Last, First, Middle Initial).: |
| Enter organization.: |
| Enter office symbol/department.: |
| Enter phone number (DSN or Commercial).: |
| Enter office email address.: |
| Enter job title and grade/rank.: |
| Enter official mailing address.: |
| Select for "citizenship - U.S.": |
| Select for "citizenship - foreign national.": |
| Select for "citizenship - OTHER.": |
| Select for "designation of person - military.": |
| Select for "designation of person - civilian.": |
| Select for "designation of person - contractor.": |
| Select for "I have completed Annual Information Awareness Training..": |
| Enter date in format YYYYMMDD.: |
| Enter user signature.: |
| Enter date in format YYYYMMDD (when item 11 is signed, this is auto filled with the date signed).: |
| Enter the justification for access.: Requesting an ART account to enter cases received at my entity, respond to cases referred to my entity, and to create and view reports. |
| Select for "user requires access to classified.: 0 |
| Select for "user requires access to classified.: 0 |
| Select for "type of access requested - privileged.": 0 |
| Select for "user requires access to unclassified.": 0 |
| Specify classified category.: |
| Select for "user requires access to other.": 0 |
| If other fill in here: |
| Select for "I certify that this user requires access as requested.": |
| Enter access expiration date (Contractors must specify Company Name, Contract Number, Expiration Date. Use Block 27 if needed.): |
| Enter supervisor's printed name.: |
| Enter supervisor's signature.: |
| Enter date in format YYYYMMDD (when item 18 is signed, this is auto filled with the date signed).: |
| Enter supervisor's organization/department.: |
| Enter supervisor's email address.: |
| Enter supervisor's phone number.: |
| Enter signature of information owner/OPR.: |
| Enter phone number.: |
| Enter date in format YYYYMMDD (when item 21 is signed, this is auto filled with the date signed).: |
| Enter signature of IA or appointee.: |
| Enter organization/department.: |
| Enter phone number.: |
| Enter date in format YYYYMMDD (when item 22 is signed, this is auto filled with the date signed).: |
| Enter name (Last, First, Middle Initial- this field is auto-filled with the value of item 1.: |
| Enter optional information.: |
Put an X next to the DHA office name of where you work:
__ THP Customer Support Division __ THP Customer Support Division-GFPTFW __ THP Clinical Operations
__ THP EQR
__ TAO Eurasia-Africa
__ TAO TLAC
__ TAO Pacific __ Benefit Education and Research Team __ Military Medical Support Office __ MHS Nurse Advice Line __ Pharmacy Operations Division __ Dental Program Office __ Other - Enter name of office:
| Enter type of investigation.: |
| Enter date in format YYYYMMDD.: |
| Enter clearance level.: |
| Enter the printed name of the verifier.: |
| Enter security manager telephone number.: |
| Enter security manager signature.: |
| Enter date in format YYYYMMDD (when item 31 is signed, this is auto filled with the date signed).: |
| Enter title, line 1.: |
| Enter system.: |
| Enter account code, line 1.: |
| Enter title, line 2.: |
| Enter domain.: |
| Enter account code, line 2.: |
| Enter title, line 3.: |
| Enter server.: |
| Enter account code, line 3.: |
| Enter title, line 4.: |
| Enter application.: |
| Enter account code, line 4.: |
| Enter title, line 5.: |
| Enter files.: |
| Enter account code, line 5.: |
| Enter title, line 6.: |
| Enter datasets.: |
| Enter account code, line 6.: |
| Enter date processed in format YYYYMMDD.: |
| Enter signature of who processed account information.: |
| Enter date in format YYYYMMDD.: |
| Enter date revalidated in format YYYYMMDD.: |
| Enter signature of who revalidated account information.: |
| Enter date in format YYYYMMDD.: |
File details come from the government source that posted it. Updated .