MEMORY STICK APPLICATION FORM

Applicant’s Details

Name
Service/Department
Organisation
Email
Telephone
Key Principles
·  Use the minimum personal information necessary and make it anonymous wherever possible.
·  Share information only where it is justified and appropriate.
·  Remove information from the memory stick as soon as possible once it has been filed securely.
·  You are responsible for the appropriate use of the stick (including shared use within a team) until the IT Service Desk is notified that it has changed ownership.
·  Use a strong password (min 8 characters; mix of upper & lowercase letters, numbers and special characters). DO NOT keep it with the memory stick.
·  Do not put confidential information on non-organisational devices/media.
·  Memory sticks may be replaced at any time following the development of an alternative, more secure solution.
·  Seek advice from Information Governance should you have any doubts/concerns.
·  If a memory stick is lost or stolen you should report it to Information Governance and the IT Service Desk as soon as possible.
Explain why you require a memory stick (all applications will be checked in detail, and clarity may be requested, which may delay the issue of the device, so please provide as much detail as possible from the outset).
Why does the information need to be copied from the organisation’s network?
Who will the information be shared with?

What information will be put on the device? (please click/cross all boxes that apply)

☐ Personal information – Patients

☐ Personal Information – Staff

☐ Corporate data – confidential

☐ Corporate data - non confidential

☐ Financial data – confidential

☐ Financial data - non confidential

☐ Other - please detail:

Budget code and contact for invoicing

(A charge of £6 will be raised for an unencrypted memory stick or a charge £50 will be raised for an encrypted memory stick)

Budget code
Name of contact for invoice

Approving manager’s details

Name
Job title
Relationship to applicant
Email
Telephone

Please email the completed form to:

Page 1 of 2 Reviewed: June 2016