Attachment_4_Madigan_CoN_Request_Form.pdf

Last Update: 12 Feb 2015

Madigan Army Medical Center Certificate of Networthiness

Request Form

MEDCOM's Networthiness program was developed due to our need to address compliance and mitigate risks associated with connecting IT resources to the Army Network.

Its purpose is to ensure that all applications, systems, devices, web services, and hardware purchases adhere to Federal, DoD, Army, and MEDCOM information assurance requirements. In effect, the program was established to determine whether an application or system is "worthy" of being connected to the Army's Enterprise network.

MEDCOM's Networthiness program proactively precludes "drive‐by" system fielding. It serves as a safety‐net for the LandWarNet (LWN) by preventing products from causing damage or interoperability issues and by mitigating risks posed to the LWN from numerous threat vectors.

The Networthiness Certification program applies to all applications, Government Off‐the‐Shelf (GOTS) products, Web Services, Collaboration Tools and Services, New, Legacy, and Fielded systems.

Enclosures & additional Requirements (indicate with check marks when completed)

Privacy Impact Assessment (PIA) CHESS Information (contact Mr Wayne Martin) (Encl 1- Statement of Non-Avail)

Network Data Flow Diagram to include Ports and Protocols Used (Encl 2)

Data Transmission Information

Will data traverse the Madigan network boundary?

YES NO

Will data traverse the MEDCOM network boundary?

YES NO

Will data travel traverse the Dept of the Army network boundary?

YES NO

If yes, to any of the above, indicate encryption technology used:

If yes, to any of the above, enter date registered with the Army

PPS:

Product (Software or Application) Information

Vendor Name:

Product Name:

Product Version Number:

If product is a suite, list all components:

(Enter all software included with the product)

Detailed Description:

(Describe what the application does, how it works, and where it will be used)

(Indicate how Madigan will benefit from the application)

System Requirements:

Describe OS - WS, Server requirements

Include devices if applicable

Requestor Information

Primary Requestor Name:

Department:

Phone Number:

Email:

Alternate Requestor Name:

Department:

Phone Number:

Email:

Vendor Information

Vendor:

Address:

Phone Number:

URL/Website:

CAGE # or DUNS #:

Cost of Ownership

Product Cost: Support Cost:

License Cost: Total Cost:

If TOTAL is $25,000 or greater, provide MSIR #: (See MISR Request Memo to obtain MSIR#) CHESS Waiver # or Code:

Continuation of Product Information/Additional Comments

Networthiness has added the requirement below. At a minimum answer the following:*

Describe in detail how this capability communicates across the network(LAN and WAN)

What is the product installed on?

How does the user access the program?

How is data entered into the application?

Does product pull data or transmit data to any other devices/systems/servers?

Where is data saved to?

Does data stay internal to the local enclave?

Revision 2 Encl1 and Encl2

26 Feb 2013 (Product info – modified to include suite info)