DHS Data Warehouse Access Request Form - Non DHS

Instructions

1.  Complete and print this form.
2.  Initial the Statement of Understanding and sign the form.
3.  Obtain your immediate supervisor's signature.
4.  Fax the form to Data Warehouse Administration at (801) 538-4016.
5.  Data Warehouse Administration will notify you if or when access has been authorized.

 

Organization:
First
Name:

Middle
Initial:

Last
Name:
Street
Address:		   Phone
Number:
City:   Email
Address:
State: Zip: Network
Logon ID:
                 

I understand that access to the Data Warehouse is for my exclusive use. I understand that this access is controlled by my password. I take responsibility for maintaining the secrecy of my password and for protecting the confidentiality of information in the Data Warehouse in accordance with the Department of Human Services Data Warehouse Access and Security Policy.  I understand that any breach of this policy may result in immediate suspension of access to the Data Warehouse and prosecution for civil and criminal damages.
Initial: 

Summarized Information Detailed Information
       
 
Requestor signature: __________________________________ Date:  _______________
 
Immediate supervisor signature: __________________________________ Date:  _______________
 
DHS Office of Executive Director: __________________________________ Date:  _______________
 
Data Warehouse signature: __________________________________ Date:  _______________
 

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