State Vital Records Office

Wisconsin Department of Health Services

(10/2014)

INSTRUCTIONS FOR COMPLETING

THE SVRIS ACCESS REQUESTAND CONFIDENTIALITY AGREEMENT

FOR DEATH EVENT USERS

If you need assistance, please contact the State SVRIS Application Administrator at

Fax: 608-261-4972

Section 1. SVRIS Action. Check the appropriate box.
Section 2..User Information.
1. Enter your SVRIS Logon ID. If you don’t have a Logon ID follow the instructions below to create your Logon ID.
  1. Go to
  2. Click on the “Self Registration” link under "Sign Up for your DOA/Wisconsin Logon.”
  3. Read the User Agreement and click “Accept.”
  4. Enter all required information. Required information is indicated by the asterisk (*) following the field. Under “Systems You Will Access,” selectDHS Vital Records. Under “Account Information,” enter the Logon ID and Password you createwhich you will use to gain access to SVRIS. Remember your Logon ID and Password. This is what you will use when working with SVRIS. Please note: the Logon ID cannot be more than 16 characters.
  5. Click "Submit" when all the required information has been entered.
2. Enter your Last Name, First Name, and Middle Initial.
3. Enter your job title.
4. Enter your contact information.Note: The email address on the written request MUST be the same as the email address you enter at when you create your Logon ID. Account activation will be delayed until the email address conflict is resolved.
5. Sign the request (required).
Section 3. Business/Facility Information. Enter the name of your business/facility, address, city, county, state, and zip code. If you work for more than one location, enter the requested contact information.
Section 4. SVRIS User Role. Check the appropriate box. Enter your Wisconsin License number or CME county code (required). All staff roles require the signature of an FD/CME/Physician to authorize the access request.
Each request must be signed by the user requesting access AND the supervisor in charge of that business/facility. Requests for office staff must have the signature of a licensed Funeral Director, CME/Deputy, or Physician before accounts can be activated. Requests not bearing all required signatures will be delayed in being processed.
SVRIS CONFIDENTIALITY AGREEMENT
Please read and complete the confidentiality agreement. Fax completed pages to (608) 261-4972.
Staff at the SVRO will complete the SVRIS account activation process and notify you when your SVRIS account is active. Activation takes approximately one week. You must have completed your training before your SVRIS account is activated.Please note: if a user’s account remains inactive for 90 days, the user account will be deactivated. In order to regain SVRIS access you will be required to resubmit a new SVRIS request with signatures.
SVRIS ACCESS REQUESTAND CONFIDENTIALITY AGREEMENT
FOR DEATH EVENT USERS
If you need assistance, please contact the State SVRIS Application Administrator at Fax: 608-261-4972
1. SVRIS Action: Please check the appropriate box below
New user Delete SVRIS user Role change
ID change (old ID)
User’s name change (Enter former name)
Location change
Delete account for previous location ______(Name of FH) / Effective Date (mm/dd/yy)
Note: The State SVRIS Administrator requires one (1) week notice prior to the effective date listed.
2. User Information: Before your account can be activated you must create a Logon ID at
SVRIS Logon ID:
Name and Title:
Email:
Phone:
Fax:
Signature (required):
3. Business/Facility Information: Enter primary and other work locations.
Primary Location
Name:
Address:
City:
County:
State: Zip
Other locations - If additional space is needed, please continue on last page
Name______
Address______City______State ______Zip______
Name______
Address______City______State ______Zip______
Name______
Address______City______State ______Zip______
Name______
Address______City______State ______Zip______
4. SVRIS User Role: Check only one.
Funeral Director Funeral Staff Corp. Funeral Home Director Corp. Funeral Home Staff
Physician Physician Staff Facility
C/ME/Dep CME Staff CME Staff View
Wisconsin License Number/CME Code (Required for Funeral Directors, Medical Examiners and Physicians):______
(Active Not Active For Vital Records Office Use Only)
Funeral Home/Facility License Number: ______
As the FD/CME/Physician, I authorize and approve this request.Signature : (Required for all staff roles)

SVRIS CONFIDENTIALITY AGREEMENT

Business Entity / Street Address
City / County / State / Zip
Name of Employee / Job Title
Work Phone / Fax Number / Work Email Address

Access to Wisconsin Vital Records is governed by Chapter 69, Wis. Statutes and DHS Administrative Rule 142 (not open records law). This Security/Confidentiality Agreement shall be signed by each SVRIS user within the above-named business entity as a condition for authorized use of SVRIS. All SVRIS users are required to accept the terms and conditions set forth in this Agreement. The employing agency agrees that, upon termination of an employee, the agency will immediately notify the State Vital Records Office by fax to (608) 261-4972 so the User Name and Password of the employee may be deactivated.

  1. Your SVRIS account is to be used only by you for official purposes related to your statutory role in the Wisconsin Vital Records program.
  2. You agree to abide by all applicable federal and state laws and policies regarding confidentiality of Wisconsin Vital Records data.
  3. You agree to respect the confidentiality and privacy of individuals whose records or data you access and to protect confidential information displayed from your workstation monitor and/or printed from SVRIS.
  4. You understand and acknowledge that SVRIS is only to be accessed by authorized users. You agree to protect the confidentiality of your Password and User Name. As an authorized user, you will not cause or permit anyone, other than yourself, to access SVRIS by use of your User Name and Password. Sharing a user account exposes the logged-in user to liability for all on-line SVRIS activities done under that user’s account. Any user found sharing his/her account with another individual may have his/her account deactivated immediately.

Signature

I have read the above and agree to abide by its provisions. I understand that violation of the provisions stated in the Agreement may cause suspension or revocation of access to SVRIS and related privileges.

Name: (Print)______

Signature: ______

Date: ______

Fax documents as soon as possible to FAX Number (608) 261-4972.Someone from SVRO will notify you that your request for access has been approved and activated. It takes approximately one week to complete the account activation process.