INSTRUCTIONS FOR NETWORK ACCESS REQUEST FORM

Section 1- Action

ADD USER:Create a new usercode.

SUSPEND USER:Suspend a usercode. List period of suspension

TERMINATE USER: Deactivate a usercode.

OTHER: Specify any action not listed that is needed for the usercode.

Section 2- User Information

NAME: Enter the first, last, and middle initial of the individual to which the usercode is assigned.

SOCIAL SECURITY NUMBER: Enter the individual’s Social Security Number.

PEOPLE FIRST ID: If APD employee, enter the individual’s People First ID. If not an APD employee o not enter.

POSITION NUMBER: Enter the individual’s current position number. If the individual is not an APD employee, enter N/A:

POSITION TITLE: Enter the individual’s current position title. If the individual has a working title that is different from the position tile, enter the working title. If the individual is not an APD employee, enter N/A.

AREA OFFICE/DDC: Enter the Area Office or Developmental DisabilitiesCenter

UNIT / SECTION: Enter the unit number to which the requester is assigned.

OFFICE ADDRESS: Enter the individual's primary work location including room number.

TELEPHONE Number: Enter the individual's work phone number with extension if applicable.

USER: Check either that the employee is a APD employee, OPS or contracted employee or

Waiver Support Coordinator

Other Client Services Provider

APD Business Partner (contracted services or than client service)

Other

EMAIL ADDRESS: (Non-APD employee only)

Section 3- Network

Check the boxes for the type of network access required.

Note: Tivoli identity management access is required for access to all DCF owned systems including email.

Section 4- Systems

Check the boxes for access to a specific system

Allocation, Budget & Contract Control System(ABC)

Budget Management System (BMS)

Consumer Directed Care Plus Purchasing Plans (CDC+)

DCF Public Assistance System (FLORIDA)

Florida Medicaid Management Information System (FMMIS)

Questionnaire for Situational Information (QSI)

Waitlist Management System (Waitlist)

Waiver Enrollment Tracking System(WETS)

Florida Safe Families Network (FSFN)

FLAIR Data Warehouse IDS Query Facility (IDS)

Lotus Notes(email)

Supported Employment Tracking System (SETS)

Other (please identify)

Section 5- Signatures

REQUESTER: The person receiving access to the network and system must sign and date the form

SUPERVISOR: The supervisor of the requesting individual or their contract manager must sign and date the form

APD IT Field Staff: APD Desktop Support Personnel must sign and date the form

ABC Security Officer: If requesting ABC access, the designated ABC security officer must sign and date the form that they have assigned this user access to the ABC system

APD IT Central Office: APD IT Central Office must sign and date the form and store a copy in a specified location.

DCF Data Security: If access to DCF-owned applications is required, this form must be signed by DCF Data Security (local or headquarters).

APD Application Owner: If granted access to a specific APD application, the designed Application owner must sign that they have granted access to the requester.

Network Access Request Form(Date Modified 02/17/2012)

Action
Effective Date:
Add User / Modify User / Suspend User / Terminate User
Period of Suspension:
User Information
Name (First) / (Last) (Middle) / Social Security Number: - -
PeopleFirst ID: / Position Number: / Position Title:
Area Office / DDC: / Unit / Section:
Office Address:
City: / Zip Code: / Telephone Number: () -
Extension:
Is the User:
APD Client Services Provider / Waiver Support Coordinator (Complete Page 5 if checked) / APD employee (includes OPS)
OtherAgency: (Specify) Contracted employee Business Partner
Network
Remote Access:
APD Network / APD Aventail (For APD employees only)
Tivoli / SSL VPN
Systems
ABC (complete page 2) / BMS / CDC+ / FLORIDA (Requires DCF Form) / FMMIS
QSI / Waitlist / WETS / FSFN (Requires DCF Form) / IDS / Lotus Notes
SETS / iBudget / Other ------

Signatures

Requester: ______Date:______

Supervisor: ______Date:______

APD IT Field Staff:______Date:______

ABC Security Officer: ______Date:______

APD IT Central ______Date:______

DCF Data Security:______Date:______

Action:
( ) Add Usercode / ( ) Delete Usercode
( ) Add Profile Levels / ( ) Change Profile Levels
Application System / Application Description / Assigned Profile Level / Changed Profile Level
ABC-BU / BUDGET…………………………
ABC-CL / CLIENT…………………………..
ABC-CO / CONTRACT..……………………
ABC-C1 / CLIENT SUB 1..………………..
ABC-C2 / APPL & REFRL SUBSYS..…..
ABC-C3 / CLIENT DELETE..……………..
ABC-C4 / COST PLAN MAINTENANCE....
ABC-DI / DISTRICT..……………………….
ABC-EM / EMPLOYEE..……………………
ABC-FA / FACILITY...………………………
ABC-IN / INVOICE ...………………………
ABC-JT / JT's, BACK-DOOR, MISC……..
ABC-LO / LOCATION………………………
ABC-MW / MEDWAIVER……………………
ABC-RC / RECONCILIATION………………
ABC-RS / RESUBMIT TO UNISYS ………
ABC-SA / SAMAS………………………….
ABC-SE / SERVICE………………………..
ABC-TM / TABLES………………………….
ABC-VE / VENDOR…………………………
ABC-WO / WORKER………………………..
ABC-CD / CROSS DIST ACCESS ………..
APPLICANT SIGNATURE: ______/ DATE:______
SUPERVISOR SIGNATURE: ______/ DATE:______
AREA ADMINISTRATOR:
______/ DATE:______
Vendor Number
Provider ID
Treating Provider ID
Agency Name
Business Email Address
Agency / Solo

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