Data Warehouse Access Request Form - Provider

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 when access has been authorized.

 

Division:
First
Name:

Middle
Initial:

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

I understand that access to the Data Warehouse is for my exclusive use and support of my work as an employee of the Department of Human Services. 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 contract termination and prosecution for civil and criminal damages.  I agree to indemnify, save harmless, and release the State of Utah, and all its officers, agents, volunteers, and employees from and against any and all loss, damages, injury, liability, suits, and proceedings which are caused in whole or in part by my negligence or the negligence of my officers, agents, volunteers, or employees, but not for claims arising from the State's sole negligence.
Initial:   

Case Management Secure Care
Community / Detention Alternative Observation / Assessment
Detention Other  
 
Requestor signature: __________________________________ Date:  _______________
 
Immediate supervisor signature: __________________________________ Date:  _______________
 
State office signature: __________________________________ Date:  _______________  
 
Data Warehouse signature: __________________________________ Date:  _______________
 

anibar.gif (9341 bytes)